What is the recommended treatment regimen for patients undergoing Percutaneous Coronary Intervention (PCI)?

Recommended Treatment Regimen for Patients Undergoing Percutaneous Coronary Intervention (PCI)

Dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor is the standard recommended treatment for patients undergoing PCI, with ticagrelor or prasugrel preferred over clopidogrel for acute coronary syndrome (ACS) patients, and treatment generally maintained for 12 months.

Initial Antiplatelet Therapy

Aspirin

• Administer aspirin to all patients without contraindications at an initial oral loading dose of 150-300 mg (or 75-250 mg IV) before PCI 1
• Continue aspirin at a maintenance dose of 75-100 mg daily indefinitely 1, 2
• Lower maintenance dose (81 mg daily) is preferable to reduce bleeding risk 1, 2

P2Y12 Inhibitor Selection

• A loading dose of a P2Y12 receptor inhibitor should be given to all patients undergoing PCI with stenting 1
• For ACS patients (NSTE-ACS or STEMI), the preferred options are:
  • Ticagrelor: 180 mg loading dose, 90 mg twice daily 1, 3
  • Prasugrel: 60 mg loading dose, 10 mg daily (only for P2Y12-inhibitor naïve patients proceeding to PCI) 1, 3
  • Clopidogrel: 600 mg loading dose, 75 mg daily (only when prasugrel or ticagrelor are not available or contraindicated) 1
• For non-ACS patients, clopidogrel is commonly used (600 mg loading dose, 75 mg daily) 1, 2

Duration of DAPT

Standard Duration

• For ACS patients receiving stents: DAPT for at least 12 months 1, 3
• For non-ACS patients receiving drug-eluting stents (DES): DAPT for at least 12 months if not at high bleeding risk 1, 2
• For non-ACS patients receiving bare-metal stents (BMS): DAPT for a minimum of 1 month and ideally up to 12 months 1

Modified Duration Based on Risk

• In patients at high bleeding risk (e.g., PRECISE-DAPT score ≥25), shorter DAPT duration (6 months) may be considered 3
• If the risk of morbidity from bleeding outweighs the anticipated benefit of 12 months of DAPT, earlier discontinuation (<12 months) is reasonable 1

Peri-Procedural Anticoagulation

• Anticoagulation is recommended for all patients during PCI in addition to antiplatelet therapy 1
• Options include:
  • Unfractionated heparin (UFH): recommended as standard choice 1
  • Enoxaparin: should be considered in patients pre-treated with subcutaneous enoxaparin 1
  • Bivalirudin: may be considered as an alternative to UFH 1
• Discontinuation of parenteral anticoagulation should be considered immediately after the procedure 1

Additional Measures to Reduce Complications

Bleeding Risk Reduction

• Use radial over femoral access for coronary procedures when performed by an expert radial operator 3
• Prescribe a proton pump inhibitor (PPI) in combination with DAPT for patients at increased risk of gastrointestinal bleeding 2, 3
• Consider genetic testing for CYP2C19 polymorphisms in high-risk patients to guide clopidogrel therapy, though not routinely recommended 4

Bailout Strategies

• Glycoprotein IIb/IIIa inhibitors should be considered for bail-out if there is evidence of no-reflow or thrombotic complications 1
• Cangrelor may be considered in P2Y12-inhibitor naïve patients undergoing PCI 1

Special Considerations

Patients Requiring Surgery During DAPT

• For non-emergent cardiac surgery, consider postponing surgery for:
  • At least 3 days after discontinuation of ticagrelor
  • At least 5 days after discontinuation of clopidogrel
  • At least 7 days after discontinuation of prasugrel 1, 5
• For urgent surgeries that cannot be delayed, proceeding with continued DAPT should be considered 5

Patients with Atrial Fibrillation

• For patients requiring oral anticoagulation after PCI, consider a double-therapy regimen of oral anticoagulant plus a P2Y12 inhibitor (preferably clopidogrel) 2
• Aspirin discontinuation is recommended 1-4 weeks after PCI with continued use of a P2Y12 inhibitor 1

Contraindications and Cautions

• Prasugrel is contraindicated in patients with prior stroke/TIA, age ≥75 years, or weight <60 kg due to increased bleeding risk 3, 6
• Avoid switching between UFH and low-molecular-weight heparin 1

Common Pitfalls to Avoid

• Not switching from clopidogrel to ticagrelor in ACS patients when indicated 3
• Discontinuing DAPT prematurely, especially within the first month after stent placement 3, 5
• Using prasugrel in patients with prior stroke or TIA (contraindicated) 3, 6
• Not prescribing a PPI with DAPT for patients at high risk of gastrointestinal bleeding 3
• Pre-treatment with GP IIb/IIIa antagonists in patients whose coronary anatomy is not known 1