Pharmacotherapy to Support PCI

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Overview

Risk Stratification and Benefits of PCI

Preparation of the Patient for PCI

Equipment Used During PCI

Pharmacotherapy to Support PCI

Vascular Closure Devices

Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

Post-PCI Management

Risk Reduction After PCI

Post-PCI follow up

Hybrid coronary revascularization

PCI approaches

PCI Complications

Factors Associated with Complications
Vessel Perforation
Dissection
Distal Embolization
No-reflow
Coronary Vasospasm
Abrupt Closure
Access Site Complications
Peri-procedure Bleeding
Restenosis
Renal Failure
Thrombocytopenia
Late Acquired Stent Malapposition
Loss of Side Branch
Multiple Complications

PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
Severely Depressed Ventricular Function
Sole Remaining Conduit
Unprotected Left Main Patient
Adjuncts for High Risk PCI

PCI in Specific Lesion Types

Classification of the Lesion
The Calcified Lesion
The Ostial Lesion
The Angulated or Tortuous Lesion
The Bifurcation Lesion
The Long Lesion
The Bridge Lesion
Vasospasm
The Chronic Total Occlusion
The Left Internal Mammary Artery
Multivessel Disease
Distal Anastomotic Lesions
Left Main Intervention
The Thrombotic Lesion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Pharmacotherapy to Support PCI

Antiplatelet Therapy to Support PCI

2021 ACA Revascularization Guideline

Class 1 Recommendation, Level of Evidence: ‌B-R[1][2][3][4][5][6][7][8][9][10][11][12][13][14]
1. A loading dose of aspirin, followed by daily dosing is recommended to reduce ischemic events in patients who are undergoing PCI.

2. A loading dose of P2Y12 inhibitor, followed by daily dosing is recommended to reduce ischemic events in patients with ACS who are undergoing PCI.

Class 1 Recommendation, Level of Evidence: C-LD [1][5][8][11][14][15][16][17]
1. A loading dose of clopidogrel, followed by daily dosing is recommended to reduce ischemic events in patients with stable ischemic heart disease (SIHD) who are undergoing PCI.

2. A loading dose of 300 mg of clopidogrel, followed by daily dosing is recommended to reduce ischemic events in patients undergoing PCI within 24 hours after fibrinolytic therapy.

Class IIa, Level of Evidence: ‌C-LD[1][18][19]
Intravenous glycoprotein IIb/IIIa inhibitors are a reasonable choice in order to improve procedural success in patients with ACS who are undergoing PCI and have a large thrombus burden, no-reflow, or slow flow.
Class 2b Recommendation, Level of Evidence: B-R [1][6][13][20][21][22][23]
1. Using ticagrelor or prasugrel is preferred to clopidogrel in order to decrease ischemic events (including stent thrombosis) in ACS patients undergoing PCI.

2. Intravenous cangrelor is recommended in order to reduce periprocedural ischemic events among P2Y12 inhibitor naïve patients who are undergoing PCI.

Class 2b Recommendation, Level of Evidence: B-R[1]
Ticagrelor could be a reasonable alternative over clopidogrel in order to decrease ischemic events in patients older than 75 years old who are undergoing PCI within 24 hours after fibrinolytic therapy.
Class 3 Recommendation: HARM, Level of Evidence: B-R[1][24][25][26]
1. Prasugrel should not be administered in patients with a history of stroke or transient ischemic attack who are undergoing PCI.

2. The routine use of an intravenous glycoprotein IIb/IIIa inhibitor is not recommended in patients with stable ischemic heart disease undergoing PCI.

Recommendations for Duration of DAPT in Patients With ACS Treated With PCI[27]

Class I
"1.In patients with ACS treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel,

prasugrel, or ticagrelor) should be given for at least 12 months(Level of Evidence: B-R)"

"2.In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended(Level of Evidence: B-NR)"
Class IIa
"1.In patients with ACS treated with DAPT after coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy(Level of Evidence: B-R)"
"2.In patients with ACS treated with DAPT after coronary stent implantation, who are not at high risk for bleeding complications and who do not have a history of stroke or TIA, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy ((Level of Evidence: B-R)"
Class IIb
"1.In patients with ACS treated with coronary stent implantation who have tolerated DAPT without bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use) continuation of DAPT for longer than 12 months may be reasonable(Level of Evidence: A SR)"
"2.In patients with ACS treated with DAPT after DES implantation who develop a high risk of bleeding (e.g., treatment with oral anticoagulant therapy), are at high risk of severe bleeding complication (e.g., major intracranial surgery), or develop significant overt bleeding, discontinuation of P2Y12 therapy after 6 months may be reasonable(Level of Evidence: C-LD)"
Class III (No Benefit)
"1.Prasugrel should not be administered to patients with a prior history of stroke or TIA(Level of Evidence: B-R)

"

Antithrombin Therapy to Support PCI

2021 ACA Revascularization Guideline

Class 1 Recommendation, Level of Evidence: C-EO[1]
Administration of intravenous unfractionated heparin (UFH) is useful in reducing ischemia events in patients undergoing PCI.
Class 1 Recommendation, Level of Evidence: C-LD[1][28][29]
Bivalirudin or argatroban should be used instead of UFH in patients with heparin-induced thrombocytopenia who are undergoing PCI.
Class 2b Recommendation, Level of Evidence: A[1][30][31][32][33][34][35][36][37][38][39]
Bivalirudin could be used as a reasonable alternative to UFH in order to reduce bleeding in patients undergoing PCI.
Class 2b Recommendation, Level of Evidence: B-BR[1][40][41][42][43][44]
In patients who have been treated with upstream subcutaneous enoxaparin for either unstable angina or NSTE-ACS, intravenous enoxaparin could be considered at the time of PCI in order to reduce ischemic events.
Class 3 Recommendation (HARM), Level of Evidence: B-R[1][41][45][46]
UFH should be avoid in patients who are on therapeutic subcutaneous enoxaparin, and have received the last dose within 12 hours of PCI due to higher rate of bleeding.

Statin Therapy to Support PCI

References

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