Pharmacotherapy to Support PCI

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Risk Stratification and Benefits of PCI

Preparation of the Patient for PCI

Equipment Used During PCI

Pharmacotherapy to Support PCI

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Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

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PCI Complications

Factors Associated with Complications
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Peri-procedure Bleeding
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Loss of Side Branch
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PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
Severely Depressed Ventricular Function
Sole Remaining Conduit
Unprotected Left Main Patient
Adjuncts for High Risk PCI

PCI in Specific Lesion Types

Classification of the Lesion
The Calcified Lesion
The Ostial Lesion
The Angulated or Tortuous Lesion
The Bifurcation Lesion
The Long Lesion
The Bridge Lesion
Vasospasm
The Chronic Total Occlusion
The Left Internal Mammary Artery
Multivessel Disease
Distal Anastomotic Lesions
Left Main Intervention
The Thrombotic Lesion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]

Pharmacotherapy to Support PCI

Antiplatelet Therapy to Support PCI

2021 ACA Revascularization Guideline

Class 1 Recommendation, Level of Evidence: ‌B-R[1][2][3][4][5][6][7][8][9][10][11][12][13][14]
1. A loading dose of aspirin, followed by daily dosing is recommended to reduce ischemic events in patients who are undergoing PCI.

2. A loading dose of P2Y12 inhibitor, followed by daily dosing is recommended to reduce ischemic events in patients with ACS who are undergoing PCI.

Class 1 Recommendation, Level of Evidence: C-LD [1][5][8][11][14][15][16][17]
1. A loading dose of clopidogrel, followed by daily dosing is recommended to reduce ischemic events in patients with stable ischemic heart disease (SIHD) who are undergoing PCI.

2. A loading dose of 300 mg of clopidogrel, followed by daily dosing is recommended to reduce ischemic events in patients undergoing PCI within 24 hours after fibrinolytic therapy.

Class IIa, Level of Evidence: ‌C-LD[1][18][19]
Intravenous glycoprotein IIb/IIIa inhibitors are a reasonable choice in order to improve procedural success in patients with ACS who are undergoing PCI and have a large thrombus burden, no-reflow, or slow flow.
Class 2b Recommendation, Level of Evidence: B-R [1][6][13][20][21][22][23]
1. Using ticagrelor or prasugrel is preferred to clopidogrel in order to decrease ischemic events (including stent thrombosis) in ACS patients undergoing PCI.

2. Intravenous cangrelor is recommended in order to reduce periprocedural ischemic events among P2Y12 inhibitor naïve patients who are undergoing PCI.

Class 2b Recommendation, Level of Evidence: B-R[1]
Ticagrelor could be a reasonable alternative over clopidogrel in order to decrease ischemic events in patients older than 75 years old who are undergoing PCI within 24 hours after fibrinolytic therapy.
Class 3 Recommendation: HARM, Level of Evidence: B-R[1][24][25][26]
1. Prasugrel should not be administered in patients with a history of stroke or transient ischemic attack who are undergoing PCI.

2. The routine use of an intravenous glycoprotein IIb/IIIa inhibitor is not recommended in patients with stable ischemic heart disease undergoing PCI.

Recommendations for Duration of DAPT in Patients With ACS Treated With PCI[27]

Class I
"1.In patients with ACS treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel,

prasugrel, or ticagrelor) should be given for at least 12 months(Level of Evidence: B-R)"

"2.In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended(Level of Evidence: B-NR)"
Class IIa
"1.In patients with ACS treated with DAPT after coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy(Level of Evidence: B-R)"
"2.In patients with ACS treated with DAPT after coronary stent implantation, who are not at high risk for bleeding complications and who do not have a history of stroke or TIA, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy ((Level of Evidence: B-R)"
Class IIb
"1.In patients with ACS treated with coronary stent implantation who have tolerated DAPT without bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use) continuation of DAPT for longer than 12 months may be reasonable(Level of Evidence: A SR)"
"2.In patients with ACS treated with DAPT after DES implantation who develop a high risk of bleeding (e.g., treatment with oral anticoagulant therapy), are at high risk of severe bleeding complication (e.g., major intracranial surgery), or develop significant overt bleeding, discontinuation of P2Y12 therapy after 6 months may be reasonable(Level of Evidence: C-LD)"
Class III (No Benefit)
"1.Prasugrel should not be administered to patients with a prior history of stroke or TIA(Level of Evidence: B-R)

"

Antithrombin Therapy to Support PCI

2021 ACA Revascularization Guideline

Class 1 Recommendation, Level of Evidence: C-EO[1]
Administration of intravenous unfractionated heparin (UFH) is useful in reducing ischemia events in patients undergoing PCI.
Class 1 Recommendation, Level of Evidence: C-LD[1][28][29]
Bivalirudin or argatroban should be used instead of UFH in patients with heparin-induced thrombocytopenia who are undergoing PCI.
Class 2b Recommendation, Level of Evidence: A[1][30][31][32][33][34][35][36][37][38][39]
Bivalirudin could be used as a reasonable alternative to UFH in order to reduce bleeding in patients undergoing PCI.
Class 2b Recommendation, Level of Evidence: B-BR[1][40][41][42][43][44]
In patients who have been treated with upstream subcutaneous enoxaparin for either unstable angina or NSTE-ACS, intravenous enoxaparin could be considered at the time of PCI in order to reduce ischemic events.
Class 3 Recommendation (HARM), Level of Evidence: B-R[1][41][45][46]
UFH should be avoid in patients who are on therapeutic subcutaneous enoxaparin, and have received the last dose within 12 hours of PCI due to higher rate of bleeding.

Statin Therapy to Support PCI

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check |pmid= value (help).
  2. ↑ Antithrombotic Trialists' Collaboration (2002). "Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients". BMJ. 324 (7329): 71–86. doi:10.1136/bmj.324.7329.71. PMC 64503. PMID 11786451. Review in: ACP J Club. 2002 Jul-Aug;137(1):5
  3. ↑ "Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration". BMJ. 308 (6921): 81–106. 1994. PMC 2539220. PMID 8298418.
  4. ↑ Antithrombotic Trialists' (ATT) Collaboration. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J; et al. (2009). "Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials". Lancet. 373 (9678): 1849–60. doi:10.1016/S0140-6736(09)60503-1. PMC 2715005. PMID 19482214. Review in: Ann Intern Med. 2009 Sep 15;151(6):JC3-4, JC3-5 Review in: Evid Based Med. 2009 Dec;14(6):172-3
  5. ↑ 5.0 5.1 Sabatine MS, Cannon CP, Gibson CM, López-Sendón JL, Montalescot G, Theroux P; et al. (2005). "Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study". JAMA. 294 (10): 1224–32. doi:10.1001/jama.294.10.1224. PMID 16143698. Review in: ACP J Club. 2006 Mar-Apr;144(2):29
  6. ↑ 6.0 6.1 Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S; et al. (2007). "Prasugrel versus clopidogrel in patients with acute coronary syndromes". N Engl J Med. 357 (20): 2001–15. doi:10.1056/NEJMoa0706482. PMID 17982182.
  7. ↑ Montalescot G, van 't Hof AW, Lapostolle F, Silvain J, Lassen JF, Bolognese L; et al. (2014). "Prehospital ticagrelor in ST-segment elevation myocardial infarction". N Engl J Med. 371 (11): 1016–27. doi:10.1056/NEJMoa1407024. PMID 25175921.
  8. ↑ 8.0 8.1 Taniuchi M, Kurz HI, Lasala JM (2001). "Randomized comparison of ticlopidine and clopidogrel after intracoronary stent implantation in a broad patient population". Circulation. 104 (5): 539–43. doi:10.1161/hc3001.093435. PMID 11479250.
  9. ↑ Bellemain-Appaix A, O'Connor SA, Silvain J, Cucherat M, Beygui F, Barthélémy O; et al. (2012). "Association of clopidogrel pretreatment with mortality, cardiovascular events, and major bleeding among patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis". JAMA. 308 (23): 2507–16. doi:10.1001/jama.2012.50788. PMID 23287889.
  10. ↑ Schömig A, Neumann FJ, Kastrati A, Schühlen H, Blasini R, Hadamitzky M; et al. (1996). "A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents". N Engl J Med. 334 (17): 1084–9. doi:10.1056/NEJM199604253341702. PMID 8598866.
  11. ↑ 11.0 11.1 Moussa I, Oetgen M, Roubin G, Colombo A, Wang X, Iyer S; et al. (1999). "Effectiveness of clopidogrel and aspirin versus ticlopidine and aspirin in preventing stent thrombosis after coronary stent implantation". Circulation. 99 (18): 2364–6. doi:10.1161/01.cir.99.18.2364. PMID 10318654.
  12. ↑ Calver AL, Blows LJ, Harmer S, Dawkins KD, Gray HH, Morgan JH; et al. (2000). "Clopidogrel for prevention of major cardiac events after coronary stent implantation: 30-day and 6-month results in patients with smaller stents". Am Heart J. 140 (3): 483–91. doi:10.1067/mhj.2000.108825. PMID 10966552.
  13. ↑ 13.0 13.1 Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C; et al. (2009). "Ticagrelor versus clopidogrel in patients with acute coronary syndromes". N Engl J Med. 361 (11): 1045–57. doi:10.1056/NEJMoa0904327. PMID 19717846. Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4
  14. ↑ 14.0 14.1 Müller C, Büttner HJ, Petersen J, Roskamm H (2000). "A randomized comparison of clopidogrel and aspirin versus ticlopidine and aspirin after the placement of coronary-artery stents". Circulation. 101 (6): 590–3. doi:10.1161/01.cir.101.6.590. PMID 10673248.
  15. ↑ Bertrand ME, Rupprecht HJ, Urban P, Gershlick AH, CLASSICS Investigators (2000). "Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting : the clopidogrel aspirin stent international cooperative study (CLASSICS)". Circulation. 102 (6): 624–9. doi:10.1161/01.cir.102.6.624. PMID 10931801.
  16. ↑ Steinhubl SR, Berger PB, Mann JT, Fry ET, DeLago A, Wilmer C; et al. (2002). "Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial". JAMA. 288 (19): 2411–20. doi:10.1001/jama.288.19.2411. PMID 12435254. Review in: ACP J Club. 2003 Jul-Aug;139(1):2
  17. ↑ von Beckerath N, Taubert D, Pogatsa-Murray G, Schömig E, Kastrati A, Schömig A (2005). "Absorption, metabolization, and antiplatelet effects of 300-, 600-, and 900-mg loading doses of clopidogrel: results of the ISAR-CHOICE (Intracoronary Stenting and Antithrombotic Regimen: Choose Between 3 High Oral Doses for Immediate Clopidogrel Effect) Trial". Circulation. 112 (19): 2946–50. doi:10.1161/CIRCULATIONAHA.105.559088. PMID 16260639.
  18. ↑ Stone GW, Maehara A, Witzenbichler B, Godlewski J, Parise H, Dambrink JH; et al. (2012). "Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial". JAMA. 307 (17): 1817–26. doi:10.1001/jama.2012.421. PMID 22447888.
  19. ↑ Montalescot G, Barragan P, Wittenberg O, Ecollan P, Elhadad S, Villain P; et al. (2001). "Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction". N Engl J Med. 344 (25): 1895–903. doi:10.1056/NEJM200106213442503. PMID 11419426. Review in: ACP J Club. 2002 May-Jun;136(3):89
  20. ↑ Montalescot G, Wiviott SD, Braunwald E, Murphy SA, Gibson CM, McCabe CH; et al. (2009). "Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial". Lancet. 373 (9665): 723–31. doi:10.1016/S0140-6736(09)60441-4. PMID 19249633. Review in: Ann Intern Med. 2009 Jun 16;150(12):JC6-10
  21. ↑ Bhatt DL, Lincoff AM, Gibson CM, Stone GW, McNulty S, Montalescot G; et al. (2009). "Intravenous platelet blockade with cangrelor during PCI". N Engl J Med. 361 (24): 2330–41. doi:10.1056/NEJMoa0908629. PMID 19915222.
  22. ↑ Bhatt DL, Stone GW, Mahaffey KW, Gibson CM, Steg PG, Hamm CW; et al. (2013). "Effect of platelet inhibition with cangrelor during PCI on ischemic events". N Engl J Med. 368 (14): 1303–13. doi:10.1056/NEJMoa1300815. PMID 23473369. Review in: Ann Intern Med. 2013 Jun 18;158(12):JC5
  23. ↑ Steg PG, Bhatt DL, Hamm CW, Stone GW, Gibson CM, Mahaffey KW; et al. (2013). "Effect of cangrelor on periprocedural outcomes in percutaneous coronary interventions: a pooled analysis of patient-level data". Lancet. 382 (9909): 1981–92. doi:10.1016/S0140-6736(13)61615-3. PMID 24011551.
  24. ↑ Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM; et al. (2004). "A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel". N Engl J Med. 350 (3): 232–8. doi:10.1056/NEJMoa031859. PMID 14724302.
  25. ↑ O'Shea JC, Hafley GE, Greenberg S, Hasselblad V, Lorenz TJ, Kitt MM; et al. (2001). "Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial: a randomized controlled trial". JAMA. 285 (19): 2468–73. doi:10.1001/jama.285.19.2468. PMID 11368699.
  26. ↑ ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy (2000). "Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial". Lancet. 356 (9247): 2037–44. doi:10.1016/S0140-6736(00)03400-0. PMID 11145489.
  27. ↑ Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA; et al. (2016). "2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". J Thorac Cardiovasc Surg. 152 (5): 1243–1275. doi:10.1016/j.jtcvs.2016.07.044. PMID 27751237.
  28. ↑ Lewis BE, Matthai WH, Cohen M, Moses JW, Hursting MJ, Leya F; et al. (2002). "Argatroban anticoagulation during percutaneous coronary intervention in patients with heparin-induced thrombocytopenia". Catheter Cardiovasc Interv. 57 (2): 177–84. doi:10.1002/ccd.10276. PMID 12357516.
  29. ↑ Mahaffey KW, Lewis BE, Wildermann NM, Berkowitz SD, Oliverio RM, Turco MA; et al. (2003). "The anticoagulant therapy with bivalirudin to assist in the performance of percutaneous coronary intervention in patients with heparin-induced thrombocytopenia (ATBAT) study: main results". J Invasive Cardiol. 15 (11): 611–6. PMID 14608128.
  30. ↑ Kastrati A, Neumann FJ, Mehilli J, Byrne RA, Iijima R, Büttner HJ; et al. (2008). "Bivalirudin versus unfractionated heparin during percutaneous coronary intervention". N Engl J Med. 359 (7): 688–96. doi:10.1056/NEJMoa0802944. PMID 18703471.
  31. ↑ Lincoff AM, Bittl JA, Harrington RA, Feit F, Kleiman NS, Jackman JD; et al. (2003). "Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention: REPLACE-2 randomized trial". JAMA. 289 (7): 853–63. doi:10.1001/jama.289.7.853. PMID 12588269.
  32. ↑ Stone GW, White HD, Ohman EM, Bertrand ME, Lincoff AM, McLaurin BT; et al. (2007). "Bivalirudin in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a subgroup analysis from the Acute Catheterization and Urgent Intervention Triage strategy (ACUITY) trial". Lancet. 369 (9565): 907–19. doi:10.1016/S0140-6736(07)60450-4. PMID 17368152.
  33. ↑ Kastrati A, Neumann FJ, Schulz S, Massberg S, Byrne RA, Ferenc M; et al. (2011). "Abciximab and heparin versus bivalirudin for non-ST-elevation myocardial infarction". N Engl J Med. 365 (21): 1980–9. doi:10.1056/NEJMoa1109596. PMID 22077909.
  34. ↑ Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T; et al. (2015). "Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial". Lancet. 385 (9986): 2465–76. doi:10.1016/S0140-6736(15)60292-6. PMID 25791214.
  35. ↑ Steg PG, van 't Hof A, Hamm CW, Clemmensen P, Lapostolle F, Coste P; et al. (2013). "Bivalirudin started during emergency transport for primary PCI". N Engl J Med. 369 (23): 2207–17. doi:10.1056/NEJMoa1311096. PMID 24171490.
  36. ↑ Stone GW, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Dudek D; et al. (2008). "Bivalirudin during primary PCI in acute myocardial infarction". N Engl J Med. 358 (21): 2218–30. doi:10.1056/NEJMoa0708191. PMID 18499566. Review in: ACP J Club. 2008 Sep 16;149(3):11
  37. ↑ Capodanno D, Gargiulo G, Capranzano P, Mehran R, Tamburino C, Stone GW (2016). "Bivalirudin versus heparin with or without glycoprotein IIb/IIIa inhibitors in patients with STEMI undergoing primary PCI: An updated meta-analysis of 10,350 patients from five randomized clinical trials". Eur Heart J Acute Cardiovasc Care. 5 (3): 253–62. doi:10.1177/2048872615572599. PMID 25746943.
  38. ↑ Cavender MA, Sabatine MS (2014). "Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: a meta-analysis of randomised controlled trials". Lancet. 384 (9943): 599–606. doi:10.1016/S0140-6736(14)61216-2. PMID 25131979.
  39. ↑ Shah R, Latham SB, Porta JM, Naz A, Matin K, Rao SV (2019). "Bivalirudin with a post-procedure infusion versus heparin monotherapy for the prevention of stent thrombosis". Catheter Cardiovasc Interv. 94 (2): 210–215. doi:10.1002/ccd.28065. PMID 30636368.
  40. ↑ Blazing MA, De Lemos JA, Dyke CK, Califf RM, Bilheimer D, Braunwald E (2001). "The A-to-Z Trial: Methods and rationale for a single trial investigating combined use of low-molecular-weight heparin with the glycoprotein IIb/IIIa inhibitor tirofiban and defining the efficacy of early aggressive simvastatin therapy". Am Heart J. 142 (2): 211–7. doi:10.1067/mhj.2001.116959. PMID 11479456.
  41. ↑ 41.0 41.1 Ferguson JJ, Califf RM, Antman EM, Cohen M, Grines CL, Goodman S; et al. (2004). "Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial". JAMA. 292 (1): 45–54. doi:10.1001/jama.292.1.45. PMID 15238590.
  42. ↑ Montalescot G, Zeymer U, Silvain J, Boulanger B, Cohen M, Goldstein P; et al. (2011). "Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for ST-elevation myocardial infarction: the international randomised open-label ATOLL trial". Lancet. 378 (9792): 693–703. doi:10.1016/S0140-6736(11)60876-3. PMID 21856483.
  43. ↑ Raffle A, Gray J, MacDonald HR (1976). "Letter: First-aid treatment of poisoning". Br Med J. 1 (6001): 93. doi:10.1136/bmj.1.6001.93-a. PMC 1638368. PMID 0.1136/bmj.e553 Check |pmid= value (help).
  44. ↑ Montalescot G, White HD, Gallo R, Cohen M, Steg PG, Aylward PE; et al. (2006). "Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention". N Engl J Med. 355 (10): 1006–17. doi:10.1056/NEJMoa052711. PMID 16957147.
  45. ↑ Drouet L, Bal dit Sollier C, Martin J (2009). "Adding intravenous unfractionated heparin to standard enoxaparin causes excessive anticoagulation not detected by activated clotting time: results of the STACK-on to ENOXaparin (STACKENOX) study". Am Heart J. 158 (2): 177–84. doi:10.1016/j.ahj.2009.05.022. PMID 19619692.
  46. ↑ Cohen M, Mahaffey KW, Pieper K, Pollack CV, Antman EM, Hoekstra J; et al. (2006). "A subgroup analysis of the impact of prerandomization antithrombin therapy on outcomes in the SYNERGY trial: enoxaparin versus unfractionated heparin in non-ST-segment elevation acute coronary syndromes". J Am Coll Cardiol. 48 (7): 1346–54. doi:10.1016/j.jacc.2006.05.058. PMID 17010793.

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