From the Guidelines
After a percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), patients should receive dual antiplatelet therapy (DAPT) consisting of aspirin 75-100mg daily indefinitely plus a P2Y12 inhibitor such as ticagrelor or prasugrel (or clopidogrel if ticagrelor or prasugrel are not available or are contraindicated) for at least 12 months, unless there are contraindications such as excessive risk of bleeding 1.
Key Recommendations
- Aspirin should be given at a maintenance dose of 75-100mg daily long-term regardless of treatment strategy 1
- A potent P2Y12 inhibitor (prasugrel or ticagrelor), or clopidogrel if these are not available or are contraindicated, is recommended before (or at latest at the time of) PCI and maintained over 12 months, unless there are contraindications such as excessive risk of bleeding 1
- A proton pump inhibitor (PPI) in combination with DAPT is recommended in patients at high risk of gastrointestinal bleeding 1
Considerations
- The use of ticagrelor or prasugrel is not recommended as part of triple antithrombotic therapy with aspirin and oral anticoagulation 1
- In patients who are at high risk of severe bleeding complications, discontinuation of P2Y12 inhibitor therapy after 6 months should be considered 1
- In high ischemic-risk patients who have tolerated DAPT without a bleeding complication, treatment with DAPT in the form of ticagrelor 60mg twice a day on top of aspirin for longer than 12 months may be considered for up to 3 years 1
From the FDA Drug Label
Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.
The treatment for STEMI after PCI includes prasugrel to reduce the rate of thrombotic cardiovascular events.
- The recommended dosage is a single 60 mg oral loading dose, followed by 10 mg orally once daily.
- Patients should also take aspirin (75 mg to 325 mg) daily 2.
- It is essential to consider the patient's weight, as those weighing less than 60 kg may require a lower maintenance dose of 5 mg to minimize the risk of bleeding 2.
From the Research
STEMI Treatment After PCI
- The cornerstone of pharmacological treatment for STEMI patients undergoing primary PCI is antithrombotic therapy, including antiplatelet and anticoagulant agents 3.
- Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor is pivotal for the acute and long-term treatment of patients with STEMI undergoing PCI 3, 4.
- Prasugrel and ticagrelor provide a more prompt, potent, and predictable antiplatelet effect compared with clopidogrel, which translates into better clinical outcomes 3, 4.
Antiplatelet Therapy Options
- Clopidogrel, prasugrel, and ticagrelor are viable options for oral P2Y12 inhibition, with prasugrel and ticagrelor being preferred over clopidogrel 3, 4, 5.
- The use of prasugrel or ticagrelor as part of triple antithrombotic therapy among patients who underwent PCI and received warfarin was associated with significantly more bleeding compared to patients who received clopidogrel 6.
- Clopidogrel was associated with reductions in major adverse cardiac events (MACE) and stroke (ischemic and hemorrhagic) following DAPT completion after PCI, compared with aspirin 7.
Treatment Considerations
- The duration of dual antiplatelet therapy (DAPT) after PCI is typically 6-12 months, followed by aspirin monotherapy indefinitely 7.
- The use of oral antiplatelet agents in STEMI patients has been questioned due to their delayed onset of action and potential adverse effects of morphine on their pharmacodynamic/pharmacokinetic profile 5.
- Future research is needed to establish which oral P2Y12 inhibitors should be administered, when, and how, in the clinical setting of STEMI 5.