Antiplatelet therapy to support PCI: Difference between revisions

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*[[ischemia|Ischemic events]] did not reduce after [[treatment]] with a [[glycoprotein IIb/IIIa receptor inhibitor]] and a [[clopidogrel]] load in [[patients]] with stable [[ischemic heart disease]].<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref><ref name="pmid11368699">{{cite journal| author=O'Shea JC, Hafley GE, Greenberg S, Hasselblad V, Lorenz TJ, Kitt MM | display-authors=etal| title=Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial: a randomized controlled trial. | journal=JAMA | year= 2001 | volume= 285 | issue= 19 | pages= 2468-73 | pmid=11368699 | doi=10.1001/jama.285.19.2468 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11368699  }} </ref>
*[[ischemia|Ischemic events]] did not reduce after [[treatment]] with a [[glycoprotein IIb/IIIa receptor inhibitor]] and a [[clopidogrel]] load in [[patients]] with stable [[ischemic heart disease]].<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref><ref name="pmid11368699">{{cite journal| author=O'Shea JC, Hafley GE, Greenberg S, Hasselblad V, Lorenz TJ, Kitt MM | display-authors=etal| title=Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial: a randomized controlled trial. | journal=JAMA | year= 2001 | volume= 285 | issue= 19 | pages= 2468-73 | pmid=11368699 | doi=10.1001/jama.285.19.2468 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11368699  }} </ref>
*ISAR-REACT (iNtra- coronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) [[clinical trail|trial]] showed a similar outcome in a group that received [[abciximab]] and a 600mg [[dose|loading dose]] of [[clopidogrel]] and another group that only received [[clopidogrel]].<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref> Furthermore, major [[bleeding]] was not significantly different among the two groups. Nevertheless, severe [[thrombocytopenia]] was significantly higher in the [[abciximab]] group.<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref>
*ISAR-REACT (iNtra- coronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) [[clinical trail|trial]] showed a similar outcome in a group that received [[abciximab]] and a 600mg [[dose|loading dose]] of [[clopidogrel]] and another group that only received [[clopidogrel]].<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref> Furthermore, major [[bleeding]] was not significantly different among the two groups. Nevertheless, severe [[thrombocytopenia]] was significantly higher in the [[abciximab]] group.<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref>
*
*A subgroup analysis of the ESPRIT (Enhance Suppression of the Platelet IIB/IIIA receptor with Integrilin Therapy) [[clinical trail|trial]] did not revealed any benefit in the primary endpoint of death, [[MI]], urgent target-vessel [[revascularization]], and thrombotic bailout with eptifibatide at 48 hours among [[patients]] who undergone [[PCI]] for [[stable angina]].<ref name="pmid11145489">{{cite journal| author=ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy| title=Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. | journal=Lancet | year= 2000 | volume= 356 | issue= 9247 | pages= 2037-44 | pmid=11145489 | doi=10.1016/S0140-6736(00)03400-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11145489  }} </ref>


===Antiplatelet Therapy In Patients Who Were Treated With Fibrinolytic Therapy===
===Antiplatelet Therapy In Patients Who Were Treated With Fibrinolytic Therapy===

Revision as of 20:32, 27 July 2022

Percutaneous coronary intervention Microchapters

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Patient Information

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
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The Left Internal Mammary Artery
Multivessel Disease
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The Thrombotic Lesion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2] Anahita Deylamsalehi, M.D.[3]

Overview

Antiplatelet Therapy to Support PCI

Oral Antiplatelets


Medication Loading Dose Maintanance Dose
Aspirin 162-325 mg (can be chewed to achieve faster action) 75-100 mg daily
Clopidogrel 600 mg (a lower loading dose of 300 mg is recommended in older patients or in patients after fibrinolytic therapy) 75 mg daily
Prasugrel 60 mg 10 mg daily
Ticagrelor 180 mg (can be chewed to achieve faster action) 90 mg twice a day

Intravenous Antiplatelets


Medication Loading Dose Maintanance Dose
Abciximab (glycoprotein IIb/IIIa inhibitor) Bolus of 0.25 mg/kg 0.125 mg/kg/min infusion (maximum 10 g/min) for 12 hours
Eptifibatide (glycoprotein IIb/IIIa inhibitor) Double bolus of 180 mg/kg (given at a 10-min interval) 2.0 mg/kg/min for up to 18 hours
Tirofiban (glycoprotein IIb/IIIa inhibitor) Bolus of 25 mg/kg over 3 minutes Infusion of 0.15 mg/kg/min for up to 18 hours
Cangrelor Bolus of 30 mg/kg Infusion 4 mg/kg/min for at least 2 hours or duration of the procedure, whichever is longer

Glycoprotein IIb/IIIa Receptor Inhibitors

Antiplatelet Therapy In Patients Who Were Treated With Fibrinolytic Therapy

2021 ACA Revascularization Guideline

Class 1 Recommendation, Level of Evidence: ‌B-R[1][18][19][20][13][22][3][38][39][40][41][42][16][43]
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][13][38][41][43][44][8][12]
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][45][30]
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][22][16][15][27][26][29]
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][33][34][35]
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.

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[46]

2011 AHA guidelines recommend the use of antiplatelet therapy aspirin (Level of Evidence: B) and P2Y12 receptor inhibitor (clopidogrel, prasugrel and ticagrelor) (Level of Evidence: A) to support PCI in patients with ACS. Few randomised trials have been conducted showing comparison of clopidogrel with aspirin and other P2Y12 inhibitors (prasugrel and ticagrelor) in terms of clinical benefit and risk of bleeding when given in patients undergoing PCI.[47][13][48][22][16] However, there is limited data comparing new P2Y12 receptor inhibitors (prasugrel and ticagrelor) for downstream and upstream therapy in patients undergoing PCI with non ST elevation MI in terms of clinical benefit and adverse effects. Hence, a new large scale randomised open label trial called DUBIUS is in process in Italy comparing two new P2Y12 inhibitors prasugrel and ticagrelor for pretreatment in patients with non ST elevation MI undergoing PCI. It is a trial designed for superiority comparing downstream therapy over upstream therapy in terms of NACE (net adverse cardaic effect) and risk of major bleeding (BARC 3, 4 and 5). Another endpoint considered in the trial is non inferiority comparison between prasugrel and ticagrelor in terms of potency of the drug for clinical benefit and NACE.

Oral Antiplatelet Therapy (DO NOT EDIT)[46]

Class I
"1. Patients already taking daily aspirin therapy should take 81 mg to 325 mg before PCI.[49][10][50] (Level of Evidence: B)"
"2. Patients not on aspirin therapy should be given non-enteric aspirin 325 mg before PCI.[49][50] (Level of Evidence: B)"
"3. After PCI, use of aspirin should be continued indefinitely.[40][18][20][51] (Level of Evidence: A)"
"4. A loading dose of a P2Y12 receptor inhibitor should be given to patients undergoing PCI with stenting.[47][13][48][22][16] (Level of Evidence: A) Options include:
a. Clopidogrel 600 mg (ACS and non-ACS patients).[47][47][13][48][22][16][13][48](Level of Evidence: B)
b. Prasugrel 60 mg (ACS patients).[47][13][48][22][16][22] (Level of Evidence: B)
c. Ticagrelor 180 mg (ACS patients).[16] (Level of Evidence: B)"
"5. The loading dose of clopidogrel for patients undergoing PCI after fibrinolytic therapy should be 300 mg within 24 hours and 600 mg more than 24 hours after receiving fibrinolytic therapy.[13][52] (Level of Evidence: C)"
"6. Patients should be counseled on the need for and risks of dual antiplatelet therapy (DAPT) before placement of intra-coronary stents, especially drug eluting stents (DES), and alternative therapies should be pursued if patients are unwilling or unable to comply with the recommended duration of dual antiplatelet therapy.[53] (Level of Evidence: C)"
"7. The duration of P2Y12 receptor inhibitor therapy after stent implantation should generally be as follows:
a. In patients receiving a stent (bare metal stent (BMS) or drug eluting stent (DES)) during PCI for ACS, P2Y12 receptor inhibitor therapy should be given for at least 12 months. Options include clopidogrel 75 mg daily [14],prasugrel 10 mg daily [22], and ticagrelor 90 mg twice daily.[16] (Level of Evidence: B)
b. In patients receiving drug eluting stent (DES) for a non-ACS indication, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding.[53][54][55] (Level of Evidence: B)
c. In patients receiving bare metal stent (BMS) for a non-ACS indication, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks).[53][8] (Level of Evidence: B)"
Class III (Harm)
"1. Prasugrel should not be administered to patients with a prior history of stroke or transient ischemic attack.[22] (Level of Evidence: B)"
Class IIa
"1. After PCI, it is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses.[10][56][57][11][58] (Level of Evidence: B)"
"2. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 receptor inhibitor therapy after stent implantation, earlier discontinuation (e.g.,less than 12 months) of P2Y12 receptor inhibitor therapy is reasonable. (Level of Evidence: C)"
Class IIb
"1. Continuation of dual antiplatelet therapy (DAPT) beyond 12 months may be considered in patients undergoing drug eluting stent (DES) implantation.[22][16] (Level of Evidence: C)"

Dual Antiplatelet Therapy Compliance and Stent Thrombosis (DO NOT EDIT) [46]

Class III (Harm)

"1. PCI with coronary stenting (BMS or DES) should not be performed if the patient is not likely to be able to tolerate and comply with dual antiplatelet therapy (DAPT) for the appropriate duration of treatment based on the type of stent implanted. [53][9][59][60](Level of Evidence: B)"

References

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