Pre-PTCA Evaluation and Preparation
All patients must receive aspirin (81-325 mg if already on therapy, or 325 mg non-enteric if aspirin-naïve) and a P2Y12 inhibitor loading dose before PCI, with the specific agent and dose determined by clinical presentation 1.
Mandatory Pre-Procedure Assessments
Risk Stratification
- Assess bleeding risk systematically before proceeding 1. Key factors include age ≥70 years, body surface area ≥1.6 m², peripheral artery disease, and female sex.
- Evaluate contrast-induced acute kidney injury (AKI) risk 1. This is a Class I recommendation with particular attention to patients with chronic kidney disease.
Renal Function Evaluation
- Estimate glomerular filtration rate (GFR) and adjust dosing of renally cleared medications accordingly 1. This is mandatory, not optional.
- For patients with creatinine clearance <60 mL/min, minimize contrast volume 1. This directly impacts procedural planning.
- Provide adequate preparatory hydration to all patients receiving contrast 1. Note: N-acetyl-L-cysteine is not recommended (Class III: No Benefit) 1.
Antiplatelet Therapy Protocol
For ACS Patients
Loading doses before PCI 1:
- Clopidogrel 600 mg, OR
- Prasugrel 60 mg, OR
- Ticagrelor 180 mg
For Non-ACS Patients
Standard clopidogrel loading appropriate to clinical scenario.
Special Case: Post-Fibrinolytic Therapy
If PCI occurs within 24 hours of fibrinolytic therapy, give clopidogrel 300 mg loading dose (not 600 mg) 2. This is a critical distinction based on the PCI-CLARITY trial showing 46% reduction in cardiovascular death, recurrent MI, or stroke without excess bleeding.
If PCI occurs >24 hours after fibrinolysis, then use 600 mg clopidogrel loading dose 1.
Allergy and Reaction History
Contrast Allergy Assessment
- Patients with prior anaphylactoid reaction to contrast media require prophylaxis before repeat administration 1. This is Class I.
- Shellfish/seafood allergy does NOT require anaphylactoid prophylaxis (Class III: No Benefit) 1. This is a common misconception to avoid.
Statin Therapy
Administer high-dose statin before PCI to reduce periprocedural MI risk 1. This is Class IIa with Level A evidence for statin-naïve patients and Level B for those on chronic statin therapy.
Patient Counseling Requirements
Counsel patients on dual antiplatelet therapy (DAPT) necessity and risks before stent placement 1. Patients must understand:
- Duration requirements (minimum 12 months for drug-eluting stents in most cases)
- Bleeding risks
- Consequences of premature discontinuation
If patients are unwilling or unable to comply with recommended DAPT duration, pursue alternative therapies 1. This is non-negotiable for drug-eluting stents.
Procedural Sedation Planning
Prepare for minimal sedation (anxiolysis) or moderate sedation 1. The critical principle: be prepared to manage one level deeper than intended. Most PCI patients maintain ability to respond purposefully to verbal commands.
Common Pitfalls to Avoid
Do not give N-acetyl-L-cysteine for contrast-induced AKI prevention—it has no benefit 1.
Do not provide anaphylactoid prophylaxis for shellfish allergy—this is not evidence-based 1.
Do not use 600 mg clopidogrel loading within 24 hours of fibrinolytic therapy—use 300 mg instead to avoid excess bleeding risk 2.
Do not proceed without documenting patient understanding of DAPT requirements—this is a Class I recommendation for informed consent 1.
Do not forget to adjust renally cleared medication doses based on GFR—this includes anticoagulants and other procedural medications 1.