P2Y12 Inhibitor After STEMI Treated with Lytics
Clopidogrel is the recommended P2Y12 inhibitor when fibrinolysis is the reperfusion strategy for STEMI, administered in addition to aspirin as soon as possible. 1
Initial P2Y12 Inhibitor Selection
Clopidogrel is specifically indicated for STEMI patients receiving thrombolytic therapy (Class I, Level A recommendation), distinguishing it from the primary PCI setting where potent P2Y12 inhibitors (prasugrel or ticagrelor) are preferred. 1
The ESC guidelines explicitly state "Clopidogrel is indicated in addition to aspirin" when fibrinolysis is the reperfusion strategy, without recommending prasugrel or ticagrelor in this specific context. 1
This differs fundamentally from primary PCI, where potent P2Y12 inhibitors (prasugrel or ticagrelor) are recommended before or at the time of PCI and maintained for 12 months. 1
Timing and Administration
Administer clopidogrel as soon as possible when initiating fibrinolytic therapy, ideally in the pre-hospital setting along with aspirin and the fibrin-specific thrombolytic agent. 1
Oral or IV aspirin should be given concurrently (Class I, Level B). 1
Transition Strategy After Angiography
All patients treated with fibrinolysis should be transferred to a PCI-capable center immediately after thrombolytic administration (Class I, Level A). 1
Angiography and PCI of the infarct-related artery should be performed between 2-24 hours after successful fibrinolysis (Class I, Level A). 1
At the time of PCI (whether routine angiography at 2-24 hours, rescue PCI for failed lysis, or emergency PCI for complications), transition to a potent P2Y12 inhibitor (prasugrel or ticagrelor) is recommended and should be maintained for 12 months unless contraindications exist. 1
Clinical Scenarios Requiring Different Approaches
Rescue PCI (Failed Fibrinolysis)
- Perform rescue PCI immediately when fibrinolysis has failed (<50% ST-segment resolution at 60-90 minutes) or with hemodynamic/electrical instability (Class I, Level A). 1
- Transition from clopidogrel to prasugrel or ticagrelor at the time of rescue PCI. 1
Emergency PCI for Complications
- Emergency angiography and PCI are recommended for patients developing heart failure/shock after fibrinolysis (Class I, Level A). 1
- Emergency PCI is indicated for recurrent ischemia or evidence of reocclusion after initial successful fibrinolysis (Class I, Level B). 1
- Switch to potent P2Y12 inhibitor at time of emergency PCI. 1
Duration and Maintenance Therapy
Continue dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) for 12 months after PCI, whether performed as routine post-lysis angiography or rescue/emergency PCI (Class I, Level A). 1
After the transition to PCI, the regimen becomes aspirin 75-100 mg daily plus ticagrelor 90 mg twice daily or prasugrel 10 mg daily (5 mg if <60 kg). 1, 2
Anticoagulation Considerations
Anticoagulation is mandatory in patients treated with lytics until revascularization or for the duration of hospital stay up to 8 days. 1
Enoxaparin IV followed by subcutaneous is preferred over unfractionated heparin (Class I, Level A). 1
Alternatively, weight-adjusted UFH IV bolus followed by infusion is acceptable (Class I, Level B). 1
Critical Pitfalls to Avoid
Do not use prasugrel or ticagrelor as the initial P2Y12 inhibitor with fibrinolytic therapy—the evidence base and guideline recommendations specifically support clopidogrel in this setting. 1
Do not delay transfer to a PCI-capable center after fibrinolysis—all patients require angiography regardless of apparent lysis success (Class I, Level A). 1
Do not continue clopidogrel after PCI is performed—escalate to prasugrel or ticagrelor at the time of coronary intervention for optimal outcomes. 1, 3
Do not miss the 2-24 hour window for routine angiography after successful fibrinolysis—this timing is evidence-based and improves outcomes (Class I, Level A). 1