From the Guidelines
Dual antiplatelet therapy (DAPT) should be used cautiously in NSTEMI patients who may need CABG surgery, with a careful assessment of the individual's bleeding and ischemic risks, as guided by the Heart Team 1. When managing NSTEMI patients in the ED, it is crucial to consider the potential need for CABG surgery and the implications of DAPT on surgical bleeding risks.
- Aspirin (162-325mg loading dose, then 81mg daily) should be administered to all NSTEMI patients, as it is recommended to continue aspirin at a low daily regimen throughout the peri-operative period 1.
- P2Y12 inhibitors like clopidogrel (300-600mg loading dose, then 75mg daily), ticagrelor (180mg loading dose, then 90mg twice daily), or prasugrel (60mg loading dose, then 10mg daily) should be delayed if CABG is anticipated within 24 hours (for ticagrelor), 5-7 days (for clopidogrel), or 7 days (for prasugrel), to allow for dissipation of the antiplatelet effect 1. The decision to initiate DAPT should balance the risk of recurrent ischemic events against potential surgical bleeding complications, with the timing of CABG being a critical factor in this decision-making process.
- For patients at low surgical risk, DAPT can be initiated, as the benefits of preventing further cardiac events often outweigh bleeding risks.
- For high-risk surgical candidates, consultation with cardiology and cardiac surgery is essential before starting P2Y12 inhibitors, and platelet function testing may be considered to guide the decision on the timing of cardiac surgery in patients who have recently received P2Y12 inhibitors 1.
From the Research
Dual Antiplatelet Therapy in NSTEMI Management
- Dual antiplatelet therapy (DAPT) is a common treatment approach for patients with non-ST-segment elevation myocardial infarction (NSTEMI) 2, 3.
- The American College of Cardiology/American Heart Association guidelines recommend DAPT for high-risk patients in the absence of contraindications 4.
Considerations for CABG Surgery
- For patients with NSTEMI who require coronary artery bypass graft (CABG) surgery, the timing of surgery is an important consideration 5, 6.
- Current guidelines do not address optimal CABG timing for NSTEMI patients, but studies suggest that delaying CABG may not improve outcomes and may increase resource use 5.
- The utilization of CABG in NSTEMI patients has remained steady over the years, with a high complication rate driven mainly by cardiac and pulmonary complications 6.
Dual Antiplatelet Therapy and CABG
- DAPT is recommended for at least 12 months for patients with ACS, including those with NSTEMI 3.
- However, the use of DAPT in patients who require CABG surgery may need to be carefully considered, as it may increase the risk of bleeding complications 3.
- There is no clear contraindication for dual antiplatelet therapy in NSTEMI management in case of a need for CABG surgery, but the decision to use DAPT should be based on individual patient characteristics and risk factors 4, 2, 3.