The following chapter devoted to antithrombotic
therapy for chronic
coronary artery disease (CAD) is part of the Antithrombotic and
Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading see the "Grades of Recommendation" chapter by Guyatt et al in this supplement, CHEST 2008; 133[suppl]:123S-131S). Among the key recommendations in this chapter are the following: for patients with non-ST-segment elevation (NSTE)-
acute coronary syndrome (ACS) we recommend daily oral
aspirin (75-100 mg) [Grade 1A]. For patients with an
aspirin allergy, we recommend
clopidogrel, 75 mg/d (Grade 1A). For patients who have received
clopidogrel and are scheduled for coronary bypass surgery, we suggest discontinuing
clopidogrel for 5 days prior to the scheduled surgery (Grade 2A). For patients after
myocardial infarction, after ACS, and those with stable CAD and patients after
percutaneous coronary intervention (PCI), we recommend daily
aspirin (75-100 mg) as indefinite
therapy (Grade 1A). We recommend
clopidogrel in combination with
aspirin for patients experiencing ST-segment elevation (STE) and NSTE-ACS (Grade 1A). For patients with
contraindications to
aspirin, we recommend
clopidogrel as monotherapy (Grade 1A). For long-term treatment after PCI in patients who receive
antithrombotic agents such as
clopidogrel or
warfarin, we recommend
aspirin (75 to 100 mg/d) [Grade 1B]. For patients who undergo bare
metal stent placement, we recommend the combination of
aspirin and
clopidogrel for at least 4 weeks (Grade 1A). We recommend that patients receiving
drug-eluting stents (DES) receive
aspirin (325 mg/d for 3 months followed by 75-100 mg/d) and
clopidogrel 75 mg/d for a minimum of 12 months (Grade 2B). For primary prevention in patients with moderate risk for a coronary event, we recommend
aspirin, 75-100 mg/d, over either no antithrombotic
therapy or
vitamin K antagonist (Grade 1A).