From the Guidelines
Percutaneous coronary intervention (PCI) therapy is recommended for acute coronary syndrome (ACS) in patients without contraindications, with the goal of rapidly restoring coronary blood flow, salvaging myocardium, reducing infarct size, improving left ventricular function, and ultimately decreasing mortality.
Key Recommendations
- PCI should be performed immediately (within 2 hours) for patients with ST-segment elevation myocardial infarction (STEMI) or for non-STEMI patients with ongoing ischemia, hemodynamic instability, electrical instability, or refractory angina 1.
- For high-risk non-STEMI patients without these urgent features, early PCI (within 24 hours) is recommended 1.
- For intermediate-risk non-STEMI patients, PCI within 72 hours is appropriate 1.
Pre-PCI Treatment
- Prior to PCI, patients typically receive antiplatelet therapy including aspirin (150-300 mg loading dose, then 75-100 mg daily) and a P2Y12 inhibitor such as ticagrelor (180 mg loading, 90 mg twice daily) or clopidogrel (300-600 mg loading, 75 mg daily) 1.
- Anticoagulation with unfractionated heparin, low molecular weight heparin, or bivalirudin is also administered 1.
Post-PCI Treatment
- Dual antiplatelet therapy (DAPT) consisting of a potent P2Y12 receptor inhibitor in addition to aspirin is generally recommended for 12 months, irrespective of the stent type, unless there are contraindications 1.
- The choice of P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) depends on individual patient characteristics and clinical judgment 1.
From the FDA Drug Label
Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.
PCI therapy is recommended for acute coronary syndrome in the following situations:
- Unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI)
- ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI 2
From the Research
PCI Therapy for Acute Coronary Syndrome
When there are no contraindications, PCI therapy is recommended for acute coronary syndrome in the following situations:
- For patients with ST-segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality from 9% to 7% 3
- For high-risk patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death from 6.5% to 4.9% 3
- For patients with STEMI, coronary catheterization and PCI within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI 3
- Transfer for cardiac catheterization/percutaneous coronary intervention (PCI) is strongly recommended in patients who manifest high-risk features and/or aggressive treatment trigger criteria, so that this high-risk subgroup may receive definitive, interventional and/or cardiology-directed specialty care at appropriate sites of care 4
Key Considerations
Some key considerations for PCI therapy in acute coronary syndrome include:
- The use of dual antiplatelet therapy comprising aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) is recommended for patients with NSTE-ACS, and those with STEMI both during and after reperfusion 5
- The choice of P2Y12 inhibitor and the duration of dual antiplatelet therapy should be based on patient characteristics, including the risk of bleeding and myocardial ischemia 6
- Anticoagulation therapy, including unfractionated heparin, low molecular weight heparin, and fondaparinux, may be used in conjunction with PCI therapy in patients with acute coronary syndrome 7