For patients with
acute coronary syndrome (ACS), the first priority is to alert emergency services. In addition to an ECG (ideally taken during the first medical contact at the patient's home), the key of life saving is the immediate antithrombotic
therapy with
acetylsalicylic acid (ASA) and (unless contraindicated) an injection of
unfractionated heparin or
bivalirudin as an alternative
anticoagulant.
Dual anti-platelet therapy (ASA combined with other
antiplatelet drugs, like
thienopyridines) should be started as soon as possible in the ambulance or at the latest in the hospital. For
clopidogrel, a loading dose of 600 mg is the standard. To avoid the risk of an unknown low or missing
clopidogrel response,
prasugrel is recommended instead, with administration of a loading dose of 60 mg, if no
contraindication (s/p
stroke or TIA) exists. When PCI is planned, the ambulance must head directly to the nearest hospital with continuous (24/7) PCI service within 90 (to 120) minutes. The maintenance dose for
clopidogrel is 75 mg/d; a daily double-dose has not proven to be superior, even in "low responders". For
prasugrel, the maintenance dose is usually 10 mg/d. To avoid
bleeding complications in patients ≥ 75 y and/or < 60 kg, a
prasugrel maintenance dose of 5 mg/d is recommended. The ESC guidelines recommend
DAPT for 1 year after ACS in all patients - independent of the type of ACS and independent of whether any or which coronary
stent has been implanted. With
DAPT, the patient - and not the
stent - is treated.