A focused update of the guideline for management of patients with unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI) was recently released. What do nurses need to know?-P.H., GA.
Laura M. Dechant, MSN, APN, CCRN, CCNS-BC, responds: The major change to the guideline is the addition of ticagrelor, a P2Y12 platelet inhibitor, to the arsenal of medications to prevent thrombosis. Ticagrelor is recommended as an alternative to clopidogrel in patients undergoing conservative (noninvasive) treatment, before or at the time of percutaneous coronary intervention (PCI). Patients receive a loading dose and continue ticagrelor postprocedure with a daily maintenance dose.1
When ticagrelor is used as part of dual antiplatelet therapy, the daily dose of aspirin should be reduced. Full-strength aspirin in combination with ticagrelor has been shown to decrease ticagrelor's efficacy.2
Major adverse reactions to ticagrelor include bleeding and dyspnea. Dyspnea is usually self-limited. If the patient is expected to undergo coronary artery bypass graft surgery, hold ticagrelor for at least 5 days prior.1
Additional recommendations include increasing the loading dose of clopidogrel for patients undergoing PCI and changing the length of time for dual antiplatelet therapy for conservative management from 1 month to up to 12 months.
Finally, early discontinuation of dual antiplatelet therapy isn't recommended in patients who require elective noncardiac procedures.1 If possible, the patient and healthcare team should defer these procedures until after the patient finishes the course of P2Y12 or consults with a cardiologist.
1. 2012 Writing Committee, Jneid H, Anderson JL, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012;126(7):875-910. [Context Link]
2. James SK, Roe MT, Cannon CP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial. BMJ. 2011;342:d3527. [Context Link]