Ticagrelor, a blood-thinning drug approved by the FDA in 2011, should be considered along with older blood thinners clopidogrel and prasugrel for treating patients who are experiencing chest pain or some heart attacks, according to joint updated guidelines issued by the American Heart Association (AHA) Task Force on Practice Guidelines and the American College of Cardiology (ACCF) Foundation.

The “focused update” on unstable angina (chest pain) or a specific kind of heart attack known as non-ST-elevation myocardial infarction (NSTEMI) is published in Circulation: Journal of the American Heart Association and the Journal of the American College of Cardiology.

The panel continues to recommend that all patients receive aspirin immediately after hospitalization, continuing as long as it is tolerated. Among the other new recommendations:

• Patients unable to take aspirin may receive prasugrel for artery-opening procedures since research on the medication is restricted to those patients. Ticagrelor or clopidogrel may be given whether patients receive medical therapy alone or are also having an invasive procedure;

• Patients undergoing invasive procedures should receive both aspirin and another antiplatelet medication;

• Patients undergoing medical treatment only should receive aspirin indefinitely and clopidogrel or ticagrelor for up to or at least 12 months.

The AHA and ACCF issue focused updates when pivotal new data are reported that may affect changes to current recommendations and meet specific criteria. One year after the last update, the biggest change is the recommendation to consider ticagrelor as a treatment option in addition to clopidogrel and prasugrel. The panel’s report highlights both the benefits (anti-clotting action) and risks (bleeding) of the new drug.

“We have put it on equal footing with two other antiplatelet medications, clopidogrel and prasugrel,” said Hani Jneid, M.D., lead author of the update and an assistant professor of medicine and director of interventional cardiology research at Baylor College of Medicine, and an interventional cardiologist at the Michael E. DeBakey VA Medical Center in Houston.

Unstable angina occurs when the heart muscle doesn’t get enough blood flow and oxygen because a coronary artery is partially blocked. In NSTEMI, there are also abnormal heart enzymes, indicating that some damage to heart muscle is already occurring.

“These conditions are very common and carry a high risk of death and recurrent heart attacks,” Jneid said. “The AHA and ACCF constantly update their guidelines so that physicians can provide patients with the most appropriate, aggressive therapy with the goal of improving health and survival.” To continue to improve the treatment of these important conditions, the panel encourages clinicians and hospitals to participate in a quality of care data registry designed to track and measure outcomes, complications and adherence to evidence-based recommendations. 

“While this focused update of the guidelines provides important guidance to clinicians, our recommendations are not substitutes for a physician’s own clinical judgments and the tailoring of therapy based on individual variability and a patient’s presentation and clinical diagnosis,” Jneid said.

Visit the American Heart Association’s website for information on the signs and symptoms of a heart attack; heart attack; unstable angina; anticoagulants and antiplatets and aspirin. 

Co-authors are Jeffrey L. Anderson, M.D., F.A.C.C., F.A.H.A.,; R. Scott Wright, M.D., F.A.C.C., F.A.H.A.; Cynthia D. Adams, R.N., Ph.D., F.A.H.A.; Charles R. Bridges, M.D., Sc.D., F.A.C.C., F.A.H.A.; Donald E. Casey, Jr, M.D., M.P.H., M.B.A., F.A.C.P., F.A.H.A.: Steven M. Ettinger, M.D., F.A.C.C.; Francis M. Fesmire, M.D., F.A.C.E.P.; Theodore G. Ganiats, M.D.; A. Michael Lincoff, M.D., F.A.C.C.; Eric D. Peterson, M.D., M.P.H., F.A.C.C., F.A.H.A.; George J. Philippides, M.D., F.A.C.C., F.A.H.A.; Pierre Theroux, M.D., .FA.C.C., F.A.H.A.; Nanette K. Wenger, M.D., M.A.C.C., F.A.H.A.; and James Patrick Zidar, M.D., F.A.C.C., F.S.C.A.I. Author disclosures are on the manuscript.

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The American Heart Association/American Stroke Association receives funding mostly from individuals. Foundations and corporations donate as well, and fund specific programs and events. Strict policies are enforced to prevent these relationships from influencing the association’s science content. Financial information for the American Heart Association, including a list of contributions from pharmaceutical companies and device manufacturers, is available at www.heart.org/corporatefunding.

The American College of Cardiology is transforming cardiovascular care and improving heart health through continuous quality improvement, patient-centered care, payment innovation and professionalism. The College is a 40,000-member nonprofit medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers, and bestows credentials upon cardiovascular specialists who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at www.cardiosource.org/ACC.