This document provides information on acute coronary syndrome (ACS). ACS refers to a spectrum of clinical presentations ranging from ST-segment elevation myocardial infarction (STEMI) to non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina. It is usually caused by acute coronary atherothrombosis. Risk factors include smoking, high cholesterol, diabetes, and family history. The document discusses gender differences in ACS presentation and outlines treatments including anti-ischemic drugs, antiplatelet therapy, anticoagulants, and revascularization procedures. It also covers STEMI and NSTEMI diagnosis and management.

1. ACUTE CORONARY
SYNDROME
PRESENTED BY : DR PUNIT GUPTA
MODERATOR : DR MRIDULATA

2. ACUTE CORONARY SYNDROME
What is ACS?
- refers to a spectrum of clinical presentations
ranging from those for ST-segment elevation myocardial
infarction (STEMI) to presentations found in non–ST-
segment elevation myocardial infarction (NSTEMI) or in
unstable angina
- in general reserved for ischemia precipitated by
acute coronary atherothrombosis

4. • Modifiable risk factors:
• smoking
• poor diet
• high cholesterol
• physical inactivity
• high blood pressure
• being overweight
• depression, social isolation and
lack of social support.

5. • Non-modifiable risk factors:
• Gender
• Age
• Family history of CVD
• Diabetes
• Human immunodeficiency virus (HIV).

6. Females, when compared to males:
-present with MI later in life
-have poorer prognosis and high morbidity
-are 2x as likely to die in the first weeks
-are more likely to die from the first MI
-have higher rates of unrecognized MI
Gender Differences

7. ACUTE CORONARY SYNDROME
Ischemic Heart
Disease
Chronic coronary artery
disease (CAD) with
STABLE ANGINA
Acute Coronary
Syndrome
STEMI
1) NSTEMI-ACS
2) Unstable Angina

8. ACUTE CORONARY SYNDROME
Classic manifestation of ischemia is angina pectoris:
Pressure,
Tightness,
Squeezing,
Heaviness,
Burning
ACS most commonly occurs without obvious precipitating
factors

9. LOCALIZATION OF CORONARY CIRCULATION IN
M.I.
ANATOMIC ECG LEADS CORONARY ARTERY
Septal V1-v2 Proximal LAD
Anterior V3-V4 LAD
Apical V5-V6 Distal LAD, LCx, or RCA
Lateral I, aVL LCx
Inferior II, III, aVF RCA(85%), LCx (15%)
RV V1-V2 & V4R (most Se) Proximal RCA
Posterior ST depression V1-V3 RCA or LCx

10. ACUTE CORONARY SYNDROME
The American
College of Cardiology (ACC) and American Heart Association (AHA)
guidelines list the following as pain descriptions uncharacteristic of
myocardial ischemia:
• Pleuritic pain (i.e., sharp or knifelike pain brought on by respiratory
movements or coughing)
• Primary or sole location of the discomfort in the middle or lower
abdominal region
• Pain that may be localized by the tip of one finger, particularly over
the left ventricular apex
• Pain reproduced with movement or palpation of the chest wall or
arms
• Constant pain that persists for many hours
• Very brief episodes of pain that last a few seconds or less
• Pain that radiates into the lower extremities

11. ISCHEMIC HEART DISEASE

12. 50% Stenosis:
there is a limitation of the ability to increase flow to
meet increased myocardial demand.
80% Stenosis:
myocardial ischemia at rest or with minimal stress
Coronary Blood Flow Limitation:
• spasm,
• arterial thrombi, and,
• rarely, coronary emboli
• as well as by ostial narrowing due to aortitis
• Congenital Anomalies

13. The severity and duration of the imbalance between
myocardial oxygen supply and demand determine
whether the damage is :
 reversible (≤20 min for total occlusion in the absence
of collaterals) or
 permanent, with subsequent myocardial necrosis
(>20 min).

14. Non-ST-Segment Elevation
Acute Coronary Syndrome
(Non-ST-Segment Elevation
Myocardial Infarction and
Unstable Angina)

15. NSTE-ACS
Pathophysiology:
1. imbalance between oxygen supply and oxygen
demand resulting from a partially occluding
thrombus forming on a disrupted
atherothrombotic coronary plaque or on
eroded coronary artery endothelium
2. dynamic obstruction
3. severe mechanical obstruction
4. increased myocardial oxygen demand

16. NSTE-ACS

17. NSTE-ACS

18. NSTE-ACS
DIAGNOSIS:
Clinical :
(1) it occurs at rest (or with minimal exertion),
lasting >10 minutes;
(2) it is of relatively recent onset (i.e., within the
prior 2 weeks); and/or
(3) it occurs with a crescendo pattern (i.e., distinctly
more severe, prolonged, or frequent than
previous episodes)
NSTEMI - elevated levels of biomarkers of cardiac necrosis

19. NSTE-ACS
DIAGNOSIS:
3 major noninvasive tools are used in the
evaluation of NSTEMI-ACS:
1. the electrocardiogram (ECG),
2. cardiac biomarkers, and
3. stress testing
GOALS :
(1) recognize or exclude myocardial infarction (MI) using
cardiac biomarkers, preferably cTn;
(2) detect rest ischemia (using serial or continuous ECGs);
and
(3) detect significant coronary obstruction at rest with CCTA
and myocardial ischemia using stress testing

21. CK-MB
1. Rapid, cost-efficient,
accurate assays
2. Ability to detect early
reinfarction
Myoglobin
1. High sensitivity
2. Useful in early detection of MI
3. Detection of reperfusion
4. Most useful in ruling out MI
Troponins
1. Powerful for
stratification
2. Greater sensitivity and
specificity than CK-MB
3. Detection of recent MI
up to 2 weeks after onset
4. Useful for selection of
therapy
5. Detection of
reperfusion
Advantages

22. CK-MB
1. Lack of specificity with
skeletal muscle
disease/injury
2. Low sensitivity during
early MI (<6 h) or late (>36
h) after symptom onset and
for minor myocardial
damage
Myoglobin
1. Very low specificity
with skeletal muscle
injury or disease
2. Rapid return to normal
Troponins
1. Low sensitivity in early
phase of MI (<6 h after
symptom onset)
2. Limited ability to detect
late minor re-infarction
Disadvantages

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25. Time from symptom onset and likely outcome
< 1 hour
Aborted heart attack or only little heart muscle damage
1–2 hours
Minor heart muscle damage only
2–4 hours
Some heart muscle damage with moderate heart muscle salvage
4–6 hours
Significant heart muscle damage with only minor heart muscle salvage
6–12 hours
No heart muscle salvage (permanent loss) with potential infarct
healing benefit
> 12 hours
Reperfusion is not routinely recommended if the patient is
asymptomatic and haemodynamically stable

27. MEDICAL TREATMENT
• Bed rest
• Continuous ECG monitoring
• Ambulation only if
No recurrence of ischemia (symptoms or ECG changes)
Does not develop an elevation of a biomarker of necrosis for
12–24 h
ANTI-ISCHEMIC ANTITHROMBOTIC

28. NSTE-ACS
Drugs Commonly Used in Intensive Medical Management of
Patients with UA and NSTEMI

29. NSTE-ACS
MEDICAL
TREATMENT
ANTI-ISCHEMIC
THERAPY
ANTITHROMBOTIC
THERAPY
antiplatelet drugs
anticoagulants.

32. NSTE-ACS
ORAL ANTIPLATELETS
Aspirin Initial dose of 325 mg nonenteric formulation followed by 75–100
mg/d of an enteric or a nonenteric formulation
Clopidogrel Loading dose of 300–600 mg followed by 75 mg/d
Prasugrel Pre-PCI: Loading dose 60 mg followed by 10 mg/d
Ticagrelor Loading dose of 180 mg followed by 90 mg twice daily
Intravenous Antiplatelet Therapy
Abciximab 0.25 mg/kg bolus followed by infusion of 0.125 μg/ kg per min
(maximum 10 μg/min) for 12–24 h
Eptifibatide 180 μg/kg bolus followed 10 min later by second bolus of 180 μg
with infusion of 2.0 μg/kg per min for 72–96 h following first bolus
Tirofiban 5 μg/kg per min followed by infusion of 0.15 μg/kg per min for 48–
96 h

33. NSTE-ACS
HEPARINS
Unfractionated
heparin
(UFH)
Bolus 70–100 U/kg (maximum 5000 U) IV followed
by infusion of 12–15 U/kg per h (initial maximum
1000 U/h) titrated to ACT 250–300 s
Enoxaparin 1 mg/kg SC every 12 h; the first dose may be preceded
by a 30-mg IV bolus; renal adjustment to
1 mg/kg once daily if creatine clearance <30 cc/min
Fondaparinux 2.5 mg SC qd
Bivalirudin Initial IV bolus of 0.75 mg/kg and an infusion of
1.75 mg/kg per h.

34. NSTE-ACS
Class I Recommendations for Use of an Early Invasive
Strategy in Patients with Non-ST-Segment Elevation
Acute Coronary Syndrome:
Class I (Level of Evidence: A) Indications
1. Recurrent angina at rest/low-level activity despite treatment
2. Elevated TnT or TnI
3. New ST-segment depression
4. CHF symptoms, rales, MR
5. EF <0.40
6. Sustained VT
7. PCI <6 months, prior CABG
8. High-risk findings from noninvasive testing
9. Hemodynamic instability
10. Mild-to-moderate renal dysfunction
11. Diabetes mellitus
12. High TIMI Risk Score (>3)b

35. NSTE-ACS
PRINZMETAL’S VARIANT ANGINA
- syndrome of severe ischemic pain that usually occurs at rest and
is associated with transient ST segment elevation
- focal spasm of an epicardial coronary artery, leading to severe
transient myocardial ischemia and occasionally infarction
- may be related to hypercontractility of vascular smooth muscle
due to adrenergic vasoconstrictors, leukotrienes, or serotonin
- has decreased substantially during the past few decades
- PVA are generally younger and have fewer coronary risk factors
- The clinical diagnosis of PVA is made by the detection of
transient ST-segment elevation with rest pain
- Focal spasm is most common in the right coronary artery

36. NSTE-ACS
PRINZMETAL’S VARIANT ANGINA
Diagnosis:
Hyperventilation or intracoronary acetylcholine has been
used to provoke focal coronary stenosis on angiography or to
provoke rest angina with ST-segment elevation to establish the
diagnosis
TREATMENT
Nitrates and Calcium Channel Blockers
Aspirin- may actually increase the severity of ischemic
episodes
PROGNOSIS
1. Survival at 5 years is excellent (∼90–95%)
2. Nonfatal MI occurs in up to 20% of patients by 5 years
3. There is a tendency for symptoms
4. and cardiac events to diminish over time

37. NSTE-ACS
CORONARY ANGIOGRAPHY
IS NOT RECOMMENDED in patients with
• extensive co-morbidities (e.g., liver or pulmonary
failure; cancer);
• in whom the risks of revascularization are not likely to
outweigh the benefits;
• in patients with acute chest pain and a low likelihood
of ACS;
• or in patients who will not consent to
revascularization regardless of the findings.

38. NSTE-ACS
Revascularization by PCI
PCI IS RECOMMENDED for NSTE-ACS patients with
1- to 2-vessel CAD, with or without significant proximal
left anterior descending CAD, but with a large area of
viable myocardium and high-risk criteria on
noninvasive testing.

39. NSTE-ACS
Revascularization by CABG Surgery
CABG IS RECOMMENDED for patients with
1. significant left main disease, and is the
preferred revascularization strategy for
patients with
2. multi-vessel coronary disease;
3. vessels with lesions not favorable for PCI;
4. depressed systolic function (LVEF lower than
50%); and diabetes.

40. NSTE-ACS
Drug/Medication Management
Strongly RECOMMENDED for patients with
1. aspirin indefinitely, and ticagrelor 90 mg twice daily
or clopidogrel 75 mg daily, for 12 months
2. underwent stenting, with aspirin indefinitely, plus
ticagrelor 90 mg twice daily or prasugrel 10 mg
daily or clopidogrel 75 mg daily, for 12 months in
patients with drug-eluting stents, and 6 months in
patients with bare metal stents
3. beta blockers be continued indefinitely for all NSTE-
ACS patients unless contraindicated

41. ST-Segment Elevation
Myocardial Infarction
(STEMI)

42. ACUTE CORONARY SYNDROME

43. ACUTE CORONARY SYNDROME

44. STEMI
Criteria for Acute Myocardial Infarction
• Detection of a rise and/or fall of cardiac biomarker values
(preferably cardiac troponin [cTn]) with at least one value
above the 99th percentile upper reference limit (URL) and
with at least one of the following:
• Symptoms of ischemia
• New or presumed new significant ST-segment T-wave (ST-T) changes or
new left bundle branch block (LBBB)
• Development of pathologic Q waves in the electrocardiogram (ECG)
• Imaging evidence of new loss of viable myocardium or new regional wall
motion abnormality
• Identification of an intracoronary thrombus by angiography or autopsy
• Cardiac death with symptoms suggestive of myocardial ischemia and
presumed new ischemic ECG changes of new LBBB, but death occurred
before cardiac biomarkers were obtained or before cardiac biomarker values
would be increased.

45. STEMI
Criteria for Acute Myocardial Infarction
• Percutaneous coronary intervention (PCI)–related MI is arbitrarily defined by
elevation of cTn values (>5 × 99th percentile URL) in patients with normal baseline
values (≤99th percentile URL) or a rise of cTn values >20% if the baseline values are
elevated and are stable or falling. In addition, either
• Coronary artery bypass grafting (CABG)–related MI is arbitrarily defined by
elevation of cardiac biomarker values (>10 × 99th percentile URL) in patients with
normal baseline cTn values (≤99th percentile URL). In addition, either
(i) symptoms suggestive of myocardial ischemia, or
(ii) new ischemic ECG changes, or
(iii) angiographic findings consistent with a procedural complication, or
(iv) imaging demonstration of new loss of viable myocardium or new regional wall motion
abnormality are required.
• Stent thrombosis associated with MI when detected by coronary angiography or
autopsy in the setting of myocardial ischemia and with a rise and/ or fall of cardiac
biomarker values with at least one value above the 99th percentile URL.
(i) new pathologic Q waves or new LBBB, or
(ii) angiographic documented new graft or new native coronary artery occlusion, or
(iii) imaging evidence of new loss of viable myocardium or new regional wall motion
abnormality.

46. STEMI
Classification of Myocardial Infarction
Type I: Spontaneous Myocardial Infarction
Type 2: Myocardial Infarction Secondary to an Ischemic
Imbalance
Type 3: Myocardial Infarction Resulting in Death When
Biomarker Values Are Unavailable
Type 4a: Myocardial Infarction Related to Percutaneous
Coronary Intervention (PCI)
Type 4b: Myocardial Infarction Related to Stent Thrombosis
Type 5: Myocardial Infarction Related to Coronary Artery
Bypass Grafting (CABG

47. STEMI
MEDICAL
TREATMENT
ANTI-ISCHEMIC
THERAPY
ANTITHROMBOTIC
THERAPY
Antiplatelet drugs
Anticoagulants
FIBRINOLYSIS

48. STEMI
the goals for the management of patients with suspected
STEMI include:
1. control of cardiac discomfort,
2. rapid identification of patients who are candidates for
urgent reperfusion therapy,
3. triage of lower-risk patients to the appropriate location
in the hospital, and
4. avoidance of inappropriate discharge of patients with
STEMI
MANAGEMENT IN THE EMERGENCY DEPARTMENT
Aspirin
is essential in the management of patients with suspected STEMI and is effective across
the entire spectrum of acute coronary syndromes
OXYGEN
O2 should be administered by nasal prongs or face mask (2–4 L/min) for
the first 6–12 h after infarction

49. STEMI
1) Sublingual nitroglycerin
Up to three doses of 0.4 mg should be administered at about 5-min intervals
2) Morphine
3) Intravenous beta blockers/ Oral Beta blockers
CONTROL OF DISCOMFORT
in the first 24 h for patients who do not
have any of the following:
(1) signs of heart failure,
(2) evidence of a low-output state,
(3) increased risk for cardiogenic shock, or
(4) other relative contraindications to beta blockade (PR interval greater than 0.24 seconds,
second- or third-degree heart block, active asthma, or reactive airway disease).
Fifteen minutes after the last intravenous dose, an oral
regimen is initiated of 50 mg every 6 h for 48 h, followed by 100
mg every 12 h

50. STEMI

51. STEMI
Initial ER Management
• Aspirin 160 to 320 mg tablet (non-enteric coated, chewed);
• Clopidogrel 300 to 600 mg whether or not fibrinolysis will be
given;
• Clopidgrel 600 mg or prasugrel 60 mg or ticagrelor 180 mg when
a patient will undergo PCI;
• Nitrates, either via sublingual or intravenous(IV) routes. Nitrates
are contraindicated in patients with hypotension or those who
took a phosphodiesterase 5 (PDE5) inhibitor within 24 hrs (48 hrs
for tadalafil);
• Morphine 2 to 4 mg IV for relief of chest pain, and;
• Supplemental oxygen MAY BE RECOMMENDED during the first 6
hours to patients with arterial oxygen saturation of less than 90%.

52. STEMI
In-hospital Treatment
Reperfusion therapy IS RECOMMENDED to all eligible
patients with STEMI with symptom onset within the
prior 12 hours.
Early revascularization, the goal being 12 hours, is a
primary treatment goal in patients with STEMI

53. STEMI

54. STEMI
Fibrinolysis
15-mg bolus followed byTPA
• 50 mg intravenously over the first 30 min,
• followed by 35 mg over the next 60 min
1.5 million units (MU) intravenously over 1 hStreptokinase
given as a single weight-based intravenous bolus
of 0.53 mg/kg over 10 s
Tenecteplase
(TNK)
double-bolus regimen consisting of a 10-MU
bolus given over 2–3 min, followed byReteplase (rPA)
• second 10-MU bolus 30 min later

55. STEMI

56. STEMI

57. STEMI
TIMI FLOW GRADE — The degree of perfusion in the
infarct-related artery (IRA) is typically described by the TIMI
flow grade:
●TIMI 0 refers to the absence of antegrade flow beyond a
coronary occlusion. (complete occlusion)
●TIMI 1 flow is faint antegrade coronary flow beyond the
occlusion, although filling of the distal coronary bed is
incomplete.
●TIMI 2 flow is delayed or sluggish antegrade flow with
complete filling of the distal territory.
●TIMI 3 flow is normal flow which fills the distal coronary
bed completely.
TIMI

58. STEMI
Primary Percutaneous Coronary
Intervention (PCI)
1. RECOMMENDED in patients with STEMI and ischemic
symptoms of less than 12 hours’ duration
2. RECOMMENDED in patients with STEMI and ischemic
symptoms of less than 12 hours’ duration who have
contraindications to fibrinolytic therapy, irrespective of
the time delay from first medical contact.
3. RECOMMENDED in patients with STEMI and cardiogenic
shock or acute severe heart failure (HF), irrespective of
time delay from MI onset
4. MAY BE RECOMMENDED in patients with STEMI if there is
clinical and/or ECG evidence of ongoing ischemia between
12 and 24 hours after symptom onset

59. STEMI
Coronary Artery Bypass Grafting (CABG)
1. IS RECOMMENDED in failed PCI with persistent pain or
hemodynamic instability in patients with coronary anatomy
suitable for surgery
2. IS RECOMMENDED in persistent or recurrent ischemia
refractory to medical therapy in patients who have coronary
anatomy suitable for surgery, and are not candidates for PCI
or fibronolytic therapy
3. RECOMMENDED in patients with STEMI at the time of
operative repair of mechanical defects.

60. STEMI
Antiplatelets and Antithrombotics
1. It IS RECOMMENDED that aspirin should be used
indefinitely in all patients with STEMI with a dosage of 75 to
162 mg/day.
2. It IS RECOMMENDED that clopidogrel 75 mg per day orally
should be added to aspirin in patients with STEMI and
maintained for at least 14 days
3. It IS RECOMMENDED that patients who are truly intolerant
to aspirin can instead receive clopidogrel 75 mg per day as
long-term secondary prevention

61. STEMI
Duration of Dual Antiplatelet Therapy and Antithrombotic
Combination Therapies after STEMI
1. Combination Therapies after STEMI DAPT by combining
aspirin and an ADP-receptor blocker (clopidogrel, prasugrel
or ticagrelor) IS RECOMMENDED in patients with STEMI
who are undergoing primary PCI (for up to 12 months) or
(clopidogrel) fibrinolysis (for up to 12 months, although the
data available pertain only to one month of DAPT), and in
those who have not undergone reperfusion therapy (for at
least 1 month and up to 12 months).

62. STEMI
Lipid Lowering Agents
1. High-dose statins are RECOMMENDED in all patients during
the first 24 hours of admission for STEMI, irrespective of the
patient’s cholesterol concentration, in the absence of
contraindications (allergy, active liver disease).
2. Atorvastatin or Rosuvastatin are recommended during the
early phase of therapy up to at least four weeks.
3. It IS RECOMMENDED to give high-dose rosuvastatin (20 to
40 mg) or atorvastatin (40 to 80 mg) therapy before
emergency percutaneous coronary intervention to
1. reduce periprocedural inflammatory response,
2. to reduce myocardial dysfunction, and
3. to prevent contrast-induced nephropathy

64. • Ventricular dysfunction
• Cardiogenic shock
• Right Ventricular Infarction
• Pericarditis
• Thromboembolism
• Left ventricular aneurysm
• Sinus bradycardia
• AV Block
• Ventricular tachycardia and fibrillation
Complications

65. THANK YOU

66. Glenn N. Levine et al. JACC 2016;68:1082-1115

67. Recommendations for Duration of DAPT in Patients With ACS Treated With Medical Therapy
Alone
COR LOE Recommendations
I B-R In patients with ACS who are managed with medical therapy alone (without revascularization or fibrinolytic
therapy) and treated with DAPT, P2Y12 inhibitor therapy (clopidogrel or ticagrelor) should be continued for
at least 12 months (52,71,140,141).
I B-NR In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is
recommended (56–60,75–78).
IIa B-R In patients with NSTE–ACS who are managed with medical therapy alone (without revascularization or
fibrinolytic therapy) and treated with DAPT, it is reasonable to use ticagrelor in preference to clopidogrel
for maintenance P2Y12 inhibitor therapy (53,71).
IIb A SR In patients with ACS treated with medical therapy alone (without revascularization or fibrinolytic therapy)
who have tolerated DAPT without bleeding complication and who are not at high bleeding risk (e.g., prior
bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT for longer than 12 months
may be reasonable (28,30,40,41,43,53,71,141).

68. Recommendations for Duration of DAPT in Patients With STEMI Treated With Fibrinolytic Therapy
COR LOE Recommendations
I A
C-EO
In patients with STEMI treated with DAPT in conjunction with fibrinolytic therapy,
P2Y12 inhibitor therapy (clopidogrel) should be continued for a minimum of 14
days (Level of Evidence: A) (140,142) and ideally at least 12 months (Level of
Evidence: C-EO).
I B-NR In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100
mg) is recommended (56–60,75–78).
IIb A SR In patients with STEMI treated with fibrinolytic therapy who have tolerated DAPT
without bleeding complication and who are not at high bleeding risk (e.g., prior
bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT for
longer than 12 months may be reasonable (16,22–
26,28,30,40,41,43,53,54,71,72,141).

69. Recommendations for Duration of DAPT in Patients With ACS Treated With PCI
COR LOE Recommendations
I B-R In patients with ACS treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy
(clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (16,50–55,72,96–98).
I B-NR In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is
recommended (56–60,75–78).
IIa B-R In patients with ACS treated with DAPT after coronary stent implantation, it is reasonable to use
ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy (53,72).
IIa B-R In patients with ACS treated with DAPT after coronary stent implantation, who are not at high risk for
bleeding complications and who do not have a history of stroke or TIA, it is reasonable to choose
prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy (54,55).
IIb A SR In patients with ACS treated with coronary stent implantation who have tolerated DAPT without
bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT,
coagulopathy, oral anticoagulant use) continuation of DAPT for longer than 12 months may be
reasonable (16,22–26,28,30,40,41,43,53,54,72).
IIb C-LD In patients with ACS treated with DAPT after DES implantation who develop a high risk of bleeding
(e.g., treatment with oral anticoagulant therapy), are at high risk of severe bleeding complication
(e.g., major intracranial surgery), or develop significant overt bleeding, discontinuation of
P2Y12 therapy after 6 months may be reasonable (17–21,34,36,37).
III:
Harm
B-R Prasugrel should not be administered to patients with a prior history of stroke or TIA (54).

70. Recommendation for Duration of DAPT in Patients With ACS Treated With CABG
COR LOE Recommendation
I C-LD In patients with ACS being treated with DAPT who undergo CABG,
P2Y12 inhibitor therapy should be resumed after CABG to complete
12 months of DAPT therapy after ACS (52–54,118–120).