What is the management for Percutaneous Coronary Intervention (PCI)?

Management of Percutaneous Coronary Intervention (PCI)

The management of patients undergoing PCI requires a comprehensive antiplatelet and anticoagulation strategy, with dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor being the cornerstone of post-PCI care to reduce mortality and prevent stent thrombosis.

Pre-PCI Management

Antiplatelet Therapy

• Aspirin: Administer oral (soluble or chewable/non-enteric-coated) or IV aspirin as soon as possible for all patients without contraindications 1
• P2Y12 Inhibitors:
  • Load with a potent P2Y12 inhibitor (prasugrel or ticagrelor) before or at latest at the time of PCI 1
  • Clopidogrel should be used if prasugrel or ticagrelor are not available or contraindicated
  • For patients ≥75 years receiving clopidogrel, start with maintenance dose rather than loading dose 1
  • Prasugrel is contraindicated in patients with history of TIA or stroke 2

Anticoagulation

• Unfractionated Heparin (UFH): Standard approach with weight-adjusted dosing 1
  • Target ACT 250-300s without GP IIb/IIIa inhibitors
  • Target ACT 200-250s with GP IIb/IIIa inhibitors 1
• Enoxaparin: Consider IV enoxaparin as an alternative to UFH 1
  • If patient received subcutaneous enoxaparin for NSTEMI:
    • If PCI within 8h of last dose: no additional anticoagulant needed
    • If PCI 8-12h after last dose: additional IV dose of 0.3 mg/kg 1
• Bivalirudin: Consider as an alternative, especially in patients with heparin-induced thrombocytopenia 1

During PCI Management

Technical Considerations

• Administer intracoronary nitroglycerin bolus to unmask potential vasospastic reactions 1
• Consider GP IIb/IIIa inhibitors for bailout if there is evidence of no-reflow or thrombotic complications 1

Management of Complications

• For no-reflow phenomenon:
  • Consider adenosine, verapamil, or nitroprusside intracoronary administration 1
  • Intra-aortic balloon pump may be helpful in severe cases 1

Post-PCI Management

Immediate Post-PCI Care (In-Hospital)

• Monitor for:

  • Recurrent myocardial ischemia
  • Hemostasis at catheter insertion site
  • Contrast-induced renal failure
  • Vascular closure device function 1

• Antiplatelet Therapy:

  • Continue aspirin indefinitely 1
  • Continue P2Y12 inhibitor (clopidogrel or ticagrelor) for up to 12 months 1

• Anticoagulant Therapy:

  • Discontinue anticoagulant therapy after PCI for uncomplicated cases 1
  • If continued anticoagulation needed, UFH can be continued for 48 hours 1

• Vascular Access Site Care:

  • Monitor for complications (occurs in up to 14% of patients) 1
  • Watch for signs of retroperitoneal hematoma: hypotension, suprainguinal tenderness, severe back or lower-quadrant abdominal pain 1
  • Monitor hematocrit for decrease greater than absolute 5-6% 1

Hospital Discharge

• Most patients can be safely discharged within the next calendar day after uncomplicated elective PCI 1
• Selected patients may be discharged on the same day, especially when the procedure is performed via radial or brachial approach 1

Long-term Management

• Secondary Prevention:
  • Implement appropriate secondary atherosclerosis prevention programs 1
  • Focus on lifestyle modification and reduction of risk factors 3
  • Ensure patient understanding and adherence to recommended medical therapies and behavior modifications 1

Special Considerations

Patients Requiring CABG After PCI

• If CABG is planned and can be delayed, P2Y12 inhibitors should be discontinued:
  • At least 5 days for clopidogrel
  • At least 7 days for prasugrel or ticagrelor 1
• Continue aspirin 1
• Discontinue GP IIb/IIIa inhibitors 4 hours before CABG 1

Cardiogenic Shock

• Emergency PCI for complete revascularization should be considered at an early stage as it may be life-saving 1
• Despite contemporary therapeutic measures, in-hospital mortality remains high in this population 4

Common Pitfalls and Caveats

1. Bleeding Risk: Carefully assess bleeding risk, especially in patients:

   • Aged ≥75 years
   • With body weight <60 kg
   • With propensity to bleed
   • On concomitant medications that increase bleeding risk 2

2. Antiplatelet Discontinuation: Avoid premature discontinuation of DAPT, particularly in the first few weeks after ACS, as it increases the risk of subsequent cardiovascular events 2

3. Crossover Between Anticoagulants: A higher risk of bleeding may result if patients cross over between different anticoagulant therapies during the index admission 1

4. Monitoring ACT with LMWH: Low-molecular-weight heparins have little effect on ACT measurements, so ACT should not be used as a guide to anticoagulation therapy in patients currently being treated with LMWH 1

5. Facilitated PCI: Routine use of facilitated PCI (full-dose lytic therapy prior to planned PCI) is not recommended as it shows no evidence of significant clinical benefit and may increase bleeding complications 1