What medications are necessary before percutaneous coronary intervention (PCI)?

Medications Necessary Before Percutaneous Coronary Intervention (PCI)

Patients undergoing PCI should receive aspirin (81-325 mg) and a loading dose of a P2Y12 receptor inhibitor before the procedure, along with appropriate anticoagulation during the procedure. 1

Antiplatelet Therapy

Aspirin

• Patients already on daily aspirin therapy should take 81-325 mg before PCI 1
• Patients not on aspirin therapy should be given non-enteric coated aspirin 325 mg before PCI 1
• After PCI, aspirin 81 mg daily is preferred over higher maintenance doses to reduce bleeding risk while maintaining efficacy 1, 2
• Aspirin should be continued indefinitely after PCI 1, 2

P2Y12 Receptor Inhibitors

• A loading dose of a P2Y12 receptor inhibitor should be administered before PCI with stenting 1
• Options include:
  • Clopidogrel: 600 mg loading dose (at least 2-6 hours before procedure when possible) 1
  • Prasugrel: 60 mg loading dose (for ACS patients) 1
  • Ticagrelor: 180 mg loading dose (for ACS patients) 1
• For patients receiving fibrinolytic therapy prior to PCI, clopidogrel loading dose should be 300 mg within 24 hours and 600 mg more than 24 hours after receiving fibrinolytic therapy 1

Anticoagulation During PCI

• Anticoagulation is recommended for all patients during PCI 1
• Options include:
  • Unfractionated heparin (UFH): recommended as routine therapy (Class I, Level C) 1
  • Enoxaparin: should be considered as an alternative to UFH (Class IIa, Level B) 1
  • Bivalirudin: may be considered in selected cases (Class IIb, Level A) 1

Glycoprotein IIb/IIIa Inhibitors

• In patients undergoing primary PCI for STEMI treated with UFH, it is reasonable to administer a GP IIb/IIIa inhibitor 1
• Options include:
  • Abciximab 1, 3
  • Double-bolus eptifibatide 1, 3
  • High-bolus dose tirofiban 1
• GP IIb/IIIa inhibitors should be considered for bail-out if there is evidence of no-reflow or thrombotic complications 1
• In patients with NSTE-ACS and high-risk features who are not adequately pre-treated with P2Y12 inhibitors, GP IIb/IIIa inhibitors are useful at the time of PCI 1

Special Considerations

Patient Counseling

• Patients should be counseled on the need for and risks of dual antiplatelet therapy (DAPT) before placement of intracoronary stents, especially drug-eluting stents 1
• Alternative therapies should be pursued if patients are unwilling or unable to comply with the recommended duration of DAPT 1

Duration of P2Y12 Inhibitor Therapy After PCI

• For ACS patients receiving any stent: P2Y12 inhibitor for at least 12 months 1
• For non-ACS patients receiving drug-eluting stent: clopidogrel for at least 12 months 1
• For non-ACS patients receiving bare-metal stent: clopidogrel for minimum 1 month and ideally up to 12 months (minimum 2 weeks if increased bleeding risk) 1

Common Pitfalls and Caveats

• Timing of P2Y12 inhibitor administration: Ideally, P2Y12 inhibitors should be given as early as possible before PCI to achieve adequate platelet inhibition at the time of the procedure 1, 4
• Prasugrel contraindication: Prasugrel should not be administered to patients with prior history of stroke or transient ischemic attack 1
• Bleeding risk assessment: If bleeding risk outweighs the anticipated benefit of the recommended duration of P2Y12 inhibitor therapy, earlier discontinuation may be considered 1
• Laboratory testing: Before administering antiplatelet and anticoagulant medications, laboratory tests should be performed to identify pre-existing hemostatic abnormalities (hematocrit, platelet count, serum creatinine, PT/aPTT) 3, 5
• Medication interactions: Be aware of potential interactions between antiplatelet agents and other medications the patient may be taking 3

By following these evidence-based recommendations for antiplatelet and anticoagulant therapy before and during PCI, clinicians can optimize outcomes by reducing ischemic complications while minimizing bleeding risk.