What is the recommended antiplatelet therapy for patients undergoing Percutaneous Coronary Intervention (PCI)?

Recommended Antiplatelet Therapy for Patients Undergoing PCI

For patients undergoing PCI, dual antiplatelet therapy (DAPT) with aspirin plus a potent P2Y12 inhibitor (preferably ticagrelor or prasugrel) is recommended for at least 12 months, with ticagrelor or prasugrel preferred over clopidogrel in ACS patients due to superior reduction in ischemic events. 1

Initial Antiplatelet Regimen

Loading Doses

• Aspirin: 150-300 mg oral loading dose (or 75-250 mg IV) 1
• P2Y12 inhibitors:
  • Ticagrelor: 180 mg loading dose 1
  • Prasugrel: 60 mg loading dose 1, 2
  • Clopidogrel: 600 mg loading dose (when ticagrelor/prasugrel unavailable or contraindicated) 1

Maintenance Doses

• Aspirin: 75-100 mg daily long-term 1
• P2Y12 inhibitors:
  • Ticagrelor: 90 mg twice daily 1
  • Prasugrel: 10 mg daily (5 mg daily for patients <60 kg) 1, 2
  • Clopidogrel: 75 mg daily 1

Selection of P2Y12 Inhibitor

Preferred Agents by Clinical Scenario

1. ACS patients undergoing PCI:

   • First choice: Ticagrelor or prasugrel 1
   • Prasugrel specifically for P2Y12-naïve patients with NSTE-ACS or STEMI 1
   • Ticagrelor for all ACS patients regardless of initial treatment strategy 1

2. Stable CAD patients undergoing PCI:

   • Clopidogrel is recommended 1

3. Contraindications for specific agents:

   • Prasugrel: Contraindicated in patients with prior stroke/TIA, generally not recommended in patients ≥75 years 2
   • Ticagrelor: Contraindicated in patients with history of intracranial hemorrhage 1

Duration of Therapy

1. Standard duration:

   • DAPT for 12 months is the default strategy for ACS patients undergoing PCI 1

2. Special considerations:

   • For patients at high bleeding risk (PRECISE-DAPT score ≥25), shorter DAPT duration may be considered 1
   • For patients at high ischemic risk with prior MI who have tolerated DAPT without bleeding complications, extended DAPT up to 36 months may be considered 1

Strategies to Minimize Bleeding Risk

1. Procedural approaches:

   • Radial access is recommended over femoral access for coronary angiography and PCI 1
   • Proton pump inhibitor is recommended in combination with DAPT, especially for patients at risk of gastrointestinal bleeding 1

2. Alternative DAPT strategies:

   • In patients who have tolerated DAPT with ticagrelor, transition to ticagrelor monotherapy is recommended ≥1 month after PCI 1, 3, 4
   • For patients requiring long-term anticoagulation, aspirin discontinuation is recommended 1-4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel) 1

Special Clinical Scenarios

1. Patients requiring surgery:

   • For non-emergent cardiac surgery, postpone surgery for:
     • At least 3 days after discontinuation of ticagrelor
     • At least 5 days after clopidogrel
     • At least 7 days after prasugrel 1
   • Continue aspirin perioperatively if bleeding risk allows 1
   • Resume P2Y12 inhibitor therapy post-operatively as soon as deemed safe 1

2. Patients with high bleeding risk:

   • Consider lower maintenance dose of prasugrel (5 mg) for patients <60 kg 2
   • Consider shorter duration of DAPT (6 months) for patients with high bleeding risk 1
   • Avoid prasugrel in patients ≥75 years unless they have diabetes or prior MI 2

Important Caveats and Pitfalls

1. Premature discontinuation risks:

   • Discontinuing DAPT prematurely significantly increases risk of stent thrombosis, MI, and death
   • Do not discontinue both antiplatelet agents shortly after PCI unless bleeding is life-threatening 1

2. Switching between P2Y12 inhibitors:

   • When switching from clopidogrel to ticagrelor, administer ticagrelor loading dose (180 mg) irrespective of timing and loading dose of clopidogrel 1
   • De-escalation from potent P2Y12 inhibitors to clopidogrel should be guided by clinical factors and/or platelet function testing 5

3. Monitoring considerations:

   • Routine platelet function testing to adjust antiplatelet therapy before or after elective stenting is not recommended 1
   • Consider platelet function testing to guide timing of cardiac surgery in patients recently treated with P2Y12 inhibitors 1

By following these evidence-based recommendations, clinicians can optimize antiplatelet therapy for patients undergoing PCI, balancing the reduction of ischemic events with the risk of bleeding complications.