What are the 2013 ACC/AHA guidelines for PCI after administration of fibrinolytic therapy in the treatment of ST-elevation myocardial infarction (STEMI) (MI, heart attack)?

Updated: May 07, 2019
  • Author: A Maziar Zafari, MD, PhD, FACC, FAHA; Chief Editor: Eric H Yang, MD  more...
  • Print
Answer

For patients undergoing PCI after receiving fibrinolytic therapy, ACC/AHA recommends the following [2] :

Class I

  • For STEMI patients treated with IV UFH: Additional boluses of UFH as needed during PCI, taking into account whether a GP IIb/IIIa receptor antagonist has been administered
  • For STEMI patients treated with enoxaparin: If the last subcutaneous dose was administered within the previous 8 hours, no additional enoxaparin should be given; if the last subcutaneous dose was received 8-12 hours prior to the procedure, an additional dose of enoxaparin 0.3 mg/kg IV  should be administered at the time of PCI.

Class III

  • PCI should not be performed with fondaparinux as the sole antithrombin agent. An additional anticoagulant with anti-IIa activity should be administered because of the risk of catheter thrombosis.

For patients undergoing PCI after receiving fibrinolytic therapy, ACC/AHA recommends the following [2] :

Class I

  • Aspirin should be continued indefinitely. (Level of evidence: A)
  • Clopidogrel 300 mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI within 24 hours of receiving fibrinolytic therapy. (Level of evidence: C)
  • Clopidogrel 600 mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI more than 24 hours after receiving fibrinolytic therapy (Level of evidence: C)
  • Administer a 75-mg dose of clopidogrel after PCI (Level of evidence: C)

Class IIa

  • After PCI, aspirin 81 mg per day is preferable to higher maintenance doses. (Level of evidence: B)
  • Prasugrel 60 mg loading dose is reasonable in patients who did not receive a previous loading dose of clopidogrel at the time of administration of a fibrinolytic agent, but it should not be given sooner than 24 hours after administration of a fibrin-specific agent or 48 hours after administration of a non–fibrin-specific agent. (Level of evidence: B)
  • A 10-mg daily maintenance dose of prasugrel is reasonable after PCI. (Level of evidence: B)

Class III

  • Prasugrel is contraindicated in patients with a previous history of stroke or transient ischemic attack. (Level of evidence: B)

Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!