Table 1.

Indications, contraindications, and precautions in using main antithrombotic drugs in ACSs

Drug	Mode of action	Indications	Contraindications	Precautions
Clopidogrel	Irreversible inhibitor of the platelet P2Y12 receptor for ADP	(with ASA): NSTE-ACS STEMI treated with thrombolysis	Acute hepatic impairment Active pathological bleeding Ischaemic stroke ≤ 7 days Glucose/galactose intolerance/malabsorption	Withhold treatment ≥ 5 days before elective surgery Renal impairment Moderate hepatic impairment PPIs other than pantoprazole
Prasugrel	Irreversible inhibitor of the platelet P2Y12 receptor for ADP	(With ASA): NSTE-ACS STEMI Both treated with PCI	Medical history of TIA/stroke Acute hepatic impairment (Child-Pugh Grade C) Active pathological bleeding Glucose/galactose intolerance/malabsorption	Patients ≥ 75 years –> 5 mg once daily maintenance dose Patients < 60 kg –> 5 mg once daily maintenance dose Mild-to-moderate hepatic impairment Renal impairment Withhold treatment ≥ 7 days before elective surgery Concomitant warfarin/NSAID
Ticagrelor	Reversible inhibitor of the platelet P2Y12 receptor for ADP	(With ASA): NSTE-ACS STEMI managed with: -medical treatment -PCI -CABG	Moderate-to-acute hepatic impairment Haemorrhagic stroke at any time Active pathological bleeding Strong CYP3A4 inhibitors (ketoconazole, clarithromycin, nefazodone, ritonavir, atazanavir) or strong CYP3A4 inducers (rifampicin, dexamethasone, phenytoin, carbamazepin, phenobarbital) uric Acid nephropathy	Predisposition to bleeding NSAID, OAT, fibrinolytic agents ≤ 24 h Digoxin P-gp inhibitors (verapamil, quinidine, cyclosporine) Withhold ≥ 5 days before CABG High risk of bradycardic events (SAND, AVB II-III, syncope) Asthma/COPD Hyperuricaemia
Abciximab	Inhibitor of platelet glycoprotein IIb/IIIa receptors	(With UFH and ASA) PCI PCI in unstable angina	Ongoing haemorrhage Cerebrovascular accident ≤ 2 years. Trauma or major cranial/spine surgery ≤ 2 months Intracranial disease Bleeding diathesis, thrombocytopaenia, vasculitis, hypertensive retinopathy Acute hepatic impairment Dialysis
Tirofiban	Inhibitor of platelet glycoprotein IIb/IIIa receptors	NSTE-ACS	Stroke ≤ 30 days or intracerebral haemorrhage at any time Intracranial disease Clinically relevant bleeding ≤ 30 days Malignant hypertension Trauma/major surgery ≤ 6 weeks Platelet count < 100 000/mm3 Coagulation or platelet function disorders Acute hepatic impairment
Eptifibatide	Inhibitor of platelet glycoprotein IIb/IIIa receptors	(With UFH and ASA) NSTE-ACS	Clinically significant hepatic impairment Acute renal impairment (eCrCl < 30 mL/min) Active bleeding ≤ 30 days Stroke ≤ 30 days or intracerebral Haemorrhage at any time Intracranial diseases Acute trauma/major surgery ≤ 6 weeks Bleeding diathesis, platelet count < 100 000/mm3, altered coagulation SBP > 200/DBP > 110 mmHg despite hypertension therapy	Women Elderly Low body weight Upstream administration
UFH	Indirect thrombin inhibitor	Prophylaxis/therapy of venous and arterial thromboembolic disease	Ongoing haemorrhagic events Propensity for haemorrhagic manifestations	Concomitant ASA
Enoxaparin	Indirect FXa and thrombin inhibitor	NSTEMI STEMI	Haemostasis disorders organic lesions at risk of bleeding Intracerebral haemorrhage at any time Acute infective endocarditis (except with mechanical prostheses)	Ticlopidine, salicylates, NSAID, antiplatelet agents Recent ischaemic stroke, peptic ulcer, uncontrolled hypertension, retinopathy, recent neurological/ophthalmic surgery Mild-to-moderate renal impairment Dose reduction with acute renal impairment Low body weight
Fondaparinux	Indirect FXa inhibitor	NSTEMI, except with PCI < 120 min STEMI treated with fibrinolysis or without reperfusion therapy	eCrCl < 20 mL/min ongoing haemorrhage acute bacterial endocarditis	Acute hepatic impairment
Bivalirudin	Direct thrombin inhibitor	(With ASA and clopidogrel) STEMI treated with primary PCI NSTE-ACS with urgent/immediate PCI PCI	eGFR < 30 mL/min/1.73 m2 active bleeding Haemostasis disorders Acute uncontrolled hypertension Subacute bacterial endocarditis	eGFR 30-50 mL/min/1.73 m2 Elderly

ADP, adenosine diphosphate; ASA, acetylsalicylic acid; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; STEMI, ST-segment elevation myocardial infarction; PPI, proton pump inhibitor; PCI, percutaneous coronary intervention; TIA, transient ischaemic attack; NSAID, non-steroidal anti-inflammatory drug; OAT, oral anticoagulant therapy; CABG, coronary artery bypass grafting; SAND, sinoatrial node disease; AVB, atrioventricular block; COPD, chronic obstructive pulmonary disease; UFH, unfractionated heparin; SBP, systolic blood pressure; DBP, diastolic blood pressure; eCrCl, estimated creatinine clearance; eGFR, estimated glomerular filtration rate.