Post-Angioplasty Management
After successful angioplasty, immediately initiate dual antiplatelet therapy (DAPT) with aspirin plus a potent P2Y12 inhibitor (prasugrel or ticagrelor preferred over clopidogrel), continue for 12 months unless bleeding risk is excessive, monitor for vascular access complications and contrast nephropathy during hospitalization, and discharge most uncomplicated patients within 24 hours with aggressive secondary prevention measures. 1
Immediate Post-Procedural Monitoring (First 24 Hours)
Antiplatelet Therapy Initiation
- Aspirin 75-100 mg daily should be continued indefinitely in all patients without contraindications 1
- Add a potent P2Y12 inhibitor immediately:
- Prasugrel (60 mg loading dose, then 10 mg daily) is recommended for P2Y12-naïve patients who proceed to PCI 1
- Ticagrelor (180 mg loading dose, then 90 mg twice daily) is recommended irrespective of pre-treatment strategy 1
- Clopidogrel (600 mg loading, then 75 mg daily) only when prasugrel or ticagrelor are unavailable or contraindicated 1
- Continue DAPT for 12 months unless excessive bleeding risk (e.g., PRECISE-DAPT score ≥25) 1
The 2019 ESC/EACTS guidelines provide the strongest evidence for this approach, with Class I, Level A-B recommendations. 1 Switching from clopidogrel to more potent agents like ticagrelor may be considered if stent thrombosis concerns arise, though this is based on lower-quality evidence. 2
Anticoagulation Management
- Discontinue all parenteral anticoagulation immediately after uncomplicated PCI 1
- For patients who received enoxaparin, sheath removal may occur 4 hours after last IV dose or 6-8 hours after last subcutaneous dose 1
- Do not continue post-procedural heparin infusions, especially when GP IIb/IIIa inhibitors were used 1
Vascular Access Site Management
- Monitor closely for vascular complications including hematoma, pseudoaneurysm, and retroperitoneal bleeding 1
- Key risk factors include female gender, older age, prolonged anticoagulation, peripheral vascular disease, and use of fibrinolytics or GP IIb/IIIa inhibitors 1
- Watch for signs of retroperitoneal hematoma: hypotension, suprainguinal tenderness, severe back or lower-quadrant abdominal pain 1
- Check post-PCI hematocrit for decrease >5-6% absolute 1
- Most vascular complications (>80%) can be managed conservatively with transfusions without surgery 1
Monitoring for Recurrent Ischemia
- Continuous ECG monitoring for ST-segment changes indicating recurrent ischemia 1
- Serial cardiac biomarkers if clinically indicated 1
- Approximately 5% of patients experience procedure-related myocardial infarction even with optimal technique and GP IIb/IIIa inhibitors 1
Contrast-Induced Nephropathy Prevention
- Monitor renal function with baseline and 24-48 hour creatinine measurements 1
- Ensure adequate hydration protocols were implemented 1
Hospital Discharge Planning (Typically Next Calendar Day)
Discharge Timing
- Most uncomplicated elective PCI patients can be safely discharged within the next calendar day 1
- Selected patients may qualify for same-day discharge, especially with radial or brachial approach, though this requires confirmation by larger studies 1
- Extended hospitalization is required if complications occur (e.g., flash pulmonary edema, significant bleeding, recurrent ischemia) 3
Secondary Prevention Measures (Critical for Long-Term Outcomes)
Medication Optimization:
- High-dose statin therapy regardless of baseline LDL 3
- Beta-blockers for all patients post-MI 3
- ACE inhibitors or ARBs, particularly if left ventricular dysfunction present 3
- Ensure patient understands and commits to 12-month DAPT adherence 1
Lifestyle Modifications:
- Cardiac rehabilitation program enrollment is strongly recommended to improve outcomes 1
- Smoking cessation counseling 1
- Dietary modifications and weight management 1
- Exercise prescription 1
Patient Education on Warning Signs
- Teach patients to recognize symptoms of stent thrombosis: sudden chest pain, shortness of breath, diaphoresis 2, 4
- Emphasize absolute importance of medication adherence, particularly DAPT 4, 5
- Never discontinue antiplatelet therapy without cardiology consultation 4, 5
Special Considerations and Common Pitfalls
Stent Thrombosis Prevention
- Stent thrombosis is a catastrophic complication with significant mortality 2, 4
- Risk is highest in the first 30 days after stent placement, particularly if DAPT is interrupted 4, 5
- Aspirin must be continued perioperatively for any future surgeries, except when bleeding risk in closed spaces significantly outweighs benefit 4
- For drug-eluting stents, elective surgery should ideally be delayed at least 1 year; for bare-metal stents, minimum 6 weeks 5
Bleeding Risk Assessment
- Patients with PRECISE-DAPT score ≥25 have excessive bleeding risk and may warrant shorter DAPT duration 1
- Balance ischemic versus bleeding risk when determining DAPT duration 6
Post-Fibrinolysis PCI Context
If PCI was performed after fibrinolytic therapy (rescue or early routine PCI), the evidence strongly supports this approach. Pooled analysis of 7 trials showed routine early PCI reduced mortality by 38% (4.4% vs 7.1%, p=0.015) and reinfarction by 41% (3.6% vs 6.1%, p=0.009) without increasing major bleeding (3.9% vs 3.2%, p=0.45). 7 These patients follow the same post-PCI management algorithm outlined above.