page170
cated, for example in those with aspirin hypersensitivity,
or when aspirin is not tolerated despite the addition of a
proton pump inhibitor.
For details on the use of clopidogrel in stroke, see below.
The
Scottish Medicines Consortium
(p.
4) has advised
(February
2004)
that
clopidogrel
be
accepted
for
restricted use for
the treatment
of
confirmed acute
coronary syndrome (without ST-segment elevation),
in
combination
with
aspirin.
Clopidogrel
should
be
initiated in hospital
inpatients only.
The
Scottish Med-
icines
Consortium
has also advised (July 2007)
that
clopidogrel
be accepted for restricted use for patients
with ST-segment elevation acute myocardial
infarction
in combination with aspirin; treatment with clopidogrel
is restricted to 4 weeks only.
Dipyridamole is used by mouth as an adjunct to oral
anticoagulation for
prophylaxis
of
thromboembolism
associated
with
prosthetic
heart
valves.
Modified-
release preparations are licensed for secondary preven-
tion of ischaemic stroke and transient ischaemic attacks
(see also Long-term Management,
under
Ischaemic
Stroke,
below).
NICE guidance
Clopidogrel and modified-release
dipyridamole in the prevention of occlusive
vascular events (December 2010)
The guidance applies to patients who have had an
occlusive vascular event,
or who have established
peripheral
arterial
disease.
The guidance does not
apply to patients who have had,
or are at
risk of,
stroke associated with atrial fibrillation, or who need
prophylaxis for occlusive events following coronary
revascularisation or carotid artery procedures.
Clopidogrel
monotherapy is
recommended as
an
option to
prevent
occlusive
vascular
events
in
patients who have had:
.
an ischaemic stroke,
or
who have peripheral
arterial disease or multivascular disease,
or
.
a myocardial infarction, only if aspirin is contra-
indicated or not tolerated.
Modified-release dipyridamole,
in combination with
aspirin,
is recommended as an option to prevent
occlusive vascular events in patients who have had:
.
a transient ischaemic attack,
or
.
an ischaemic stroke,
only if clopidogrel
is con-
tra-indicated or not tolerated.
Modified-release
dipyridamole
monotherapy
is
recommended as an option to prevent
occlusive
vascular events in patients who have had:
.
an ischaemic stroke, only if aspirin and clopido-
grel are contra-indicated or not tolerated,
or
.
a transient
ischaemic attack,
only if
aspirin is
contra-indicated or not tolerated.
Prasugrel,
in combination with aspirin,
is licensed for
the prevention of
atherothrombotic events in patients
with acute coronary syndrome undergoing percuta-
neous coronary intervention (section 2.10.1);
the com-
bination is usually given for up to 12 months.
The
Scottish Medicines Consortium
(p.
4) has advised
(August 2009) that prasugrel
(
Efient
c
),
in combination
with aspirin, be accepted for restricted use within NHS
Scotland for the prevention of atherothrombotic events
in patients with acute coronary syndrome undergoing
percutaneous coronary intervention who are eligible to
receive the 10 mg dose of prasugrel.
NICE guidance
Prasugrel for the treatment of acute
coronary syndromes with percutaneous
coronary intervention (October 2009)
Prasugrel,
in combination with aspirin,
is an option
for
the prevention of
atherothrombotic events in
patients with acute coronary syndromes undergoing
percutaneous coronary intervention,
only when:
.
immediate
primary
percutaneous
coronary
intervention is necessary for ST-segment eleva-
tion myocardial infarction,
or
.
stent
thrombosis
occurred during
treatment
with clopidogrel,
or
.
the patient has diabetes mellitus.
Patients selected for percutaneous coronary interven-
tion, with the placement of a coronary stent, will require
dual antiplatelet therapy with aspirin and clopidogrel, or
aspirin and prasugrel.
Aspirin therapy should continue
indefinitely.
Clopidogrel
is recommended for 1 month
following elective percutaneous coronary intervention
with placement of a bare-metal stent, and for 12 months
if
percutaneous coronary intervention with placement
of
a
bare-metal
stent
was
for
an acute
coronary
syndrome;
clopidogrel
should be given for 12 months
following placement of a drug-eluting stent. Clopidogrel
should not be discontinued prematurely in patients with
a drug-eluting stent—there is an increased risk of stent
thrombosis as a result of the eluted drug slowing the re-
endothelialisation process.
Patients considered to be at
high risk of
developing late stent
thrombosis with a
drug-eluting stent
may require a longer
duration of
treatment with clopidogrel.
Prasugrel
is an alternative
to clopidogrel
in certain patients undergoing percuta-
neous coronary intervention (see notes above).
Glycoprotein IIb/IIIa inhibitors
Glycoprotein IIb/
IIIa inhibitors prevent platelet aggregation by blocking
the binding of
fibrinogen to receptors
on platelets.
Abciximab is a monoclonal
antibody which binds to
glycoprotein IIb/IIIa receptors
and to other
related
sites; it is licensed as an adjunct to unfractionated hep-
arin and aspirin for the prevention of
ischaemic com-
plications in high-risk patients undergoing percutaneous
transluminal
coronary intervention.
Abciximab should
be used once only (to avoid additional risk of thrombo-
cytopenia).
Eptifibatide and tirofiban also inhibit gly-
coprotein IIb/IIIa receptors;
they are licensed for use
with unfractionated heparin and aspirin to prevent early
myocardial infarction in patients with unstable angina or
non-ST-segment-elevation myocardial
infarction (sec-
tion 2.10.1). Abciximab, eptifibatide and tirofiban should
be used by specialists only.
For use of epoprostenol, see section 2.8.1.
Management of stroke
Stroke is associated with a significant risk of morbidity
and mortality. Patients presenting with acute symptoms
should be immediately transferred to hospital for accu-
rate diagnosis of
stroke type,
and urgent
initiation of
appropriate treatment; patients should be managed by a
specialist multidisciplinary stroke team.
The following notes give an overview of the initial
and
long-term management
of
transient
ischaemic attack,
ischaemic stroke,
and intracerebral haemorrhage.
150
2.9 Antiplatelet drugs
BNF 61
2
Cardiovascular system