Version July 2025
ACS: acute coronary syndrome; DAPT: dual antiplatelet therapy; PCI: percutaneous coronary intervention; STEMI: ST-elevation myocardial infarction; TIA: transient ischemic attack.
* The doses for aspirin and the P2Y12 inhibitors are discussed in detail in UpToDate topics on antiplatelet therapy for acute STEMI.
¶ In patients who undergo fibrinolysis, we recommend transfer of the patient for coronary angiography and possible PCI within 6 to 24 hours of fibrinolysis regardless of the apparent success of initial fibrinolysis. For details on this strategy, refer to UpToDate topics on choice of reperfusion strategy.
Δ In patients who will receive primary PCI, DAPT (ie, aspirin plus a P2Y12 inhibitor) should be started as soon as the diagnosis of STEMI is confirmed. Provision of P2Y12 inhibitor should not delay transport to the catheterization suite for PCI.
◊ In patients who present with acute STEMI and currently take aspirin, a P2Y12 inhibitor, an oral anticoagulant, or a combination of these agents, our experts administer antiplatelet agents as though they were not taking such agents (eg, provide a loading dose of clopidogrel). Following the acute phase of management and before discharge, the short-term strategy typically includes aspirin, a P2Y12 inhibitor, and anticoagulation for 30 days. After 30 days, the long-term plan for antiplatelet therapies is individualized based on the need for ongoing anticoagulation and the patient's characteristics. Refer to UpToDate topics on management of the anticoagulation and antiplatelet regimen in ACS for additional details.
