What medications are recommended for patients undergoing angioplasty?

Medications for Patients Undergoing Angioplasty

For patients undergoing angioplasty, a dual antiplatelet therapy (DAPT) regimen consisting of aspirin plus a P2Y12 inhibitor is strongly recommended, along with appropriate anticoagulation during the procedure. 1, 2

Pre-Procedural Antiplatelet Therapy

Aspirin

• Patients already taking daily aspirin therapy should take 81-325 mg before PCI 1, 2
• Patients not on aspirin therapy should be given non-enteric coated aspirin 325 mg before PCI 1, 2
• Aspirin 162-325 mg should be given before primary PCI for STEMI patients 1

P2Y12 Inhibitor Loading Doses

• A loading dose of a P2Y12 receptor inhibitor should be given as early as possible or at the time of primary PCI 1, 2
• Options include:
  • Clopidogrel 600 mg 1
  • Prasugrel 60 mg (contraindicated in patients with prior stroke/TIA) 1, 3
  • Ticagrelor 180 mg 1

Anticoagulation During PCI

• Unfractionated heparin (UFH) is recommended as routine anticoagulant therapy during PCI 1, 2
• In patients at high risk of bleeding, bivalirudin monotherapy is reasonable in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist 1
• Enoxaparin may be considered as an alternative to UFH 1
• Fondaparinux should not be used as the sole anticoagulant for PCI due to risk of catheter thrombosis 1

Glycoprotein IIb/IIIa Inhibitors

• In selected high-risk patients undergoing primary PCI for STEMI, GP IIb/IIIa inhibitors may be administered in conjunction with UFH or bivalirudin 1
• Options include:
  • Abciximab: 0.25 mg/kg IV bolus, then 0.125 mcg/kg/min (maximum 10 mcg/min) 1
  • Tirofiban (high-bolus dose): 25 mcg/kg IV bolus, then 0.15 mcg/kg/min 1

Post-Procedural Antiplatelet Therapy

Aspirin

• After PCI, aspirin should be continued indefinitely 1
• 81 mg daily is the preferred maintenance dose over higher doses to reduce bleeding risk while maintaining efficacy 1, 2

P2Y12 Inhibitor Maintenance Doses and Duration

• For patients receiving a stent during PCI for ACS, P2Y12 inhibitor therapy should be given for at least 12 months 1, 2

  • Clopidogrel 75 mg daily 1
  • Prasugrel 10 mg daily (contraindicated in patients with prior stroke/TIA) 1, 3
  • Ticagrelor 90 mg twice daily 1

• For patients receiving a drug-eluting stent (DES) for a non-ACS indication:

  • P2Y12 inhibitor (typically clopidogrel 75 mg daily) should be given for at least 12 months 1

• For patients receiving a bare-metal stent (BMS) for a non-ACS indication:

  • P2Y12 inhibitor therapy should be given for a minimum of 1 month and ideally up to 12 months 1

Special Considerations

Stent Selection

• Bare-metal stents should be used in patients with high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive/surgical procedures in the next year 1
• Drug-eluting stents should not be used in patients unable to tolerate or comply with prolonged DAPT due to increased risk of stent thrombosis 1

Bleeding Risk Management

• If the risk of morbidity from bleeding outweighs the anticipated benefit of recommended DAPT duration, earlier discontinuation (e.g., <12 months) may be considered 1
• Patients should be counseled on the need for and risks of DAPT before placement of intracoronary stents, especially DES 1, 2

Prasugrel Contraindications

• Prasugrel should not be administered to patients with a prior history of stroke or transient ischemic attack 1, 3
• For patients ≥75 years of age, prasugrel is generally not recommended due to increased bleeding risk 1, 3
• For patients weighing <60 kg, consider reducing prasugrel maintenance dose to 5 mg daily due to increased bleeding risk 1, 3

Medication Counseling

• Patients should be informed that they will bruise and bleed more easily while on DAPT 3
• Patients should be instructed not to discontinue antiplatelet therapy without first discussing with their physician 3
• Patients should inform all healthcare providers about their antiplatelet regimen before any invasive procedures 3