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Content Update

March 18, 2019

Additional Antithrombotic Therapy for the Secondary Prevention of Acute Coronary Syndrome: Vorapaxar and low-dose rivaroxaban have been approved for the prevention of atherothrombotic events in patients with a history of stable coronary artery disease. This strategy represents a different approach for long-term prevention than prolonged dual antiplatelet therapy or aspirin monotherapy. While both new therapies reduce ischemic events in high-risk patient populations, major and/or fatal bleeding complications are also increased, though the net clinical benefit continues to favor enhanced antithrombotic therapy. Societal guidelines providing recommendations for the place of these novel therapies in practice have not been developed at this time and providers should carefully weigh risks and benefits prior to use.

Content Update

April 10, 2017

Making Anticoagulant-Antiplatelet Combination Therapy Safer: Patients with atrial fibrillation (AF) who are at high risk of stroke traditionally receive warfarin therapy. These AF patients who also have ischemic heart disease and undergo coronary artery stent placement are candidates for dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor plus low-dose aspirin. However, triple therapy (warfarin plus DAPT) greatly increases bleeding risk in these patients. The PIONEER AF-PCI study showed that once-daily rivaroxaban and a P2Y12 inhibitor (eg, clopidogrel) appears to be safer and more convenient than warfarin plus DAPT in patients with AF who receive a coronary artery stent.


For the chapter in the Wells Handbook, please go to Chapter 5. Acute Coronary Syndromes.



  • image The cause of an acute coronary syndrome (ACS) is the rupture of an atherosclerotic plaque with subsequent platelet adherence, activation, and aggregation, and the activation of the clotting cascade. Ultimately, a clot forms composed of fibrin and platelets.

  • image National guidelines exist for ACS patient care for ST-segment elevation (STE) myocardial infarction (MI) and non–ST-segment elevation (NSTE) ACS, including guidelines for patients undergoing percutaneous coronary intervention (PCI).

  • image Patients with ischemic chest discomfort and suspected ACS are risk-stratified based on a 12-lead electrocardiogram (ECG), clinical presentation, past medical history, and results of the troponin assays. The diagnosis of MI is confirmed based on the results of the troponin biochemical marker tests.

  • image Early reperfusion therapy with primary PCI of the infarct artery is recommended for patients presenting with STEMI within 12 hours of symptom onset.

  • image The most recent PCI practice guidelines recommend coronary angiography with either PCI or coronary artery bypass graft (CABG) surgery revascularization as an early treatment (early invasive strategy) for patients with NSTE-ACS at an elevated risk for death or MI, including those with a high risk score or patients with refractory angina, acute heart failure, other symptoms of cardiogenic shock, or arrhythmias.

  • image In addition to reperfusion therapy, other early pharmacotherapy that all patients with STEMI and without contraindications should receive within the first day of hospitalization, and preferably in the emergency department (ED), are intranasal oxygen (if oxygen saturation is ...

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