When to stop Tirofiban (Aggrastat) infusion after percutaneous coronary intervention (PCI)?

When to Stop Tirofiban After PCI

Tirofiban infusion should be continued for 12 to 24 hours after percutaneous coronary intervention (PCI), with most evidence supporting discontinuation at approximately 12-18 hours post-procedure. 1

Evidence-Based Duration Guidelines

Standard Post-PCI Duration

The optimal duration is 12-24 hours after PCI completion, based on landmark trials and current guidelines:

• In the PRISM-PLUS trial, tirofiban infusion was maintained for 12-24 hours after angioplasty/atherectomy, with an average continuation of 15 hours post-procedure 2
• ACC/AHA guidelines from 2000 and 2011 consistently recommend continuing the infusion for 12-24 hours after the intervention 1
• European Heart Journal guidelines (2002) specify that the infusion should be continued for 12 hours (for abciximab) or 24 hours (for eptifibatide and tirofiban) after the procedure 1

Pharmacokinetic Rationale

The 12-24 hour window is supported by tirofiban's pharmacokinetic profile:

• Tirofiban has a plasma half-life of 1.5-2 hours, with platelet function recovering to 50% of baseline within 4 hours after stopping the infusion 3
• Receptor blockade is rapidly reversible, occurring within 4-6 hours of discontinuation 4
• ADP-induced platelet aggregation returns to near-baseline levels within 4-8 hours after cessation 5

Maximum Infusion Duration

The total duration of tirofiban therapy should not exceed 108 hours (4.5 days):

• In PRISM-PLUS, tirofiban and heparin could be continued for up to 108 hours total, including the pre-PCI medical stabilization period 2
• Patients received an average of 71 hours of tirofiban therapy in the trial 2

Clinical Context Considerations

High-Risk ACS Patients

For patients with unstable angina/NSTEMI undergoing PCI, the 12-24 hour post-procedure window remains standard:

• The benefit of tirofiban was maintained when continued through and after revascularization procedures 1
• Approximately 30% of PRISM-PLUS patients underwent angioplasty/atherectomy during the study, with continued benefit observed 2

Renal Impairment

Patients with severe renal insufficiency require dose adjustment but the same duration:

• The maintenance infusion should be reduced to 0.075 mcg/kg/min (50% reduction) for creatinine clearance ≤60 mL/min 3
• The half-life is prolonged more than three times in severe renal insufficiency 4
• Duration of 12-24 hours post-PCI remains appropriate with adjusted dosing 6

Common Pitfalls to Avoid

Do not stop tirofiban prematurely (before 12 hours post-PCI):

• Early discontinuation may compromise the periprocedural protection against thrombotic complications 1
• The greatest benefit is observed during and immediately after the intervention 1

Do not extend beyond 24 hours post-PCI in routine cases:

• Prolonged infusion increases bleeding risk without additional benefit 1
• Major bleeding complications are increased with GP IIb/IIIa antagonists compared to placebo (2.4% vs 1.4%) 1

Monitor for bleeding complications throughout the infusion:

• Major bleeding should prompt immediate discontinuation 2
• Platelet count should be monitored, as thrombocytopenia (<90,000 cells/µL) occurs slightly more frequently with tirofiban 5

1, 3, 4, 2, 5, 6