Multisocietal update adds ticagrelor to NSTEMI guidelines

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In an update of guidelines that outline care for patients with unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI), task force members determined that ticagrelor should be considered along with clopidogrel and prasugrel for antiplatelet therapy. Aspirin retained its position as the first-line therapy for NSTEMI patients immediately after hospitalization.

The update, jointly issued by the American Heart Association and the American College of Cardiology, was simultaneously published online July 16 in Circulation and the Journal of the American College of Cardiology. It updates the 2007 guidelines and replaces a 2011 focused update.

“The focused update is not intended to be based on a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that may affect changes to current recommendations,” according to the writing group.

The authors recommended that ticagrelor (Brilinta, AstraZeneca), which was approved by the FDA in 2011, should join two older drugs as a Class I recommendation for treating patients who present with chest pain or NSTEMI.  “We have put it on equal footing with two other antiplatelet medications, clopidogrel and prasugrel,” said lead author Hani Jneid, MD, in a statement. Jneid is director of interventional cardiology research at Baylor College of Medicine and an interventional cardiologist at the Michael E. DeBakey VA Medical Center, both in Houston, and served as writing group chair.

“Aspirin should be administered to UA/NSTEMI patients as soon as possible after hospital presentation and continued indefinitely in patients who tolerate it (Level of Evidence: A),” Jneid and colleagues wrote. “A loading dose followed by daily maintenance dose of either clopidogrel (Level of Evidence: B), prasugrel (in PCI-treated patients, Level of Evidence: C), or ticagrelor (Level of Evidence: C) should be administered to UA/NSTEMI patients who are unable to take aspirin because of hypersensitivity or major GI [gastrointestinal] intolerance.”

In issuing a class of recommendation, task force members estimate the size of the treatment effect while weighing risks and benefits along with effectiveness and potential to cause harm. Class I indicates a benefit far surpassing risk. Class recommendation is augmented by a level of evidence, A through C, that estimates the certainty or precision of the treatment effect.  

The authors continued that patients at medium to high risk who have been selected for an invasive procedure should receive dual antiplatelet therapy at presentation, ranking the level of evidence as A. Aspirin also should be initiated with a second antiplatelet therapy added. Physician choices before PCI include clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi-Aventis), ticagrelor or an IV GP IIb/IIIa inhibitor. At the time of PCI, their options include the three drugs as well as prasugrel (Effient, Eli Lilly/Daiichi Sankyo).

The task force introduced a new term, guideline-directed medical therapy, to represent what the guidelines define as optimal medical therapy. These primarily are Class I recommendations. The authors wrote that from now on the term will be included in guidelines.

The update addressed early hospital care; late-hospital, discharge and post-discharge care; guidance on treating patient with diabetes and chronic kidney disease; and future directions. The authors emphasized the importance of developing regional systems for caring for UA/NSTEMI patients, and encouraged physicians and hospitals to take part in performance and quality measures through registries.

The focused update is available here.