Antiplatelet therapy to support PCI: Difference between revisions

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Latest revision as of 08:00, 6 August 2022

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S [2] Anahita Deylamsalehi, M.D.[3]

Overview

Dual anti-platelet therapy (aspirin and oral P2Y12 inhibitors) is the main therapy for the prevention of thrombotic complications in patients with PCI. It has been recommended to avoid routine P2Y12 inhibitor treatment in patients with stable angina whose coronary anatomy is unknown. Antiplatelet medications are divided into those which can be used orally or intravenously. Clopidogrel, ticagrelor and prasugrel are the common present-day oral P2Y12 inhibitors with different dosage, characteristics and considerations. On the other hand, aspirin has been used as a key agent in prevention of coronary thrombosis with balloon angioplasty and in patients with chronic vascular disease. Usage of aspirin is recommended in the periprocedural period due to its effect on reducing ischemic complications after PCI. Intravenous antiplatelets such as abciximab, eptifibatide, tirofiban, and cangrelor have been studied in different clinical trials. Among these medications only cangrelor is a P2Y12 inhibitor and the other ones are glycoprotein IIb/IIIa inhibitor. Antiplatelet therapy in STEMI patients who had been treated with fibrinolytics who are undergoing PCI is high risk due to higher rate of bleeding and ischemia. However, clopidogrel was studied in conjunction with fibrinolytic therapy and led to 46% lower rate of cardiovascular death, recurrent MI and stroke within the 30 days after PCI with an unchanged rate of minor and major bleeding.

Antiplatelet Therapy to Support PCI

Dual anti-platelet therapy (aspirin and oral P2Y12 inhibitors) is the main therapy for the prevention of thrombotic complications in patients with PCI.^[1]
There is no evidence to support routine pretreatment with a P2Y12 inhibitor in patients with stable angina before coronary angiography when the coronary anatomy is not known.^[2]^[3]^[4]^[5]^[6]^[7] This statement is important since a considerable proportion of patients who has been sent for PCI still may require CABG and pretreatment with P2Y12 inhibitor will delay the surgery.^[8]

Oral Antiplatelets

The following are the contemporary oral P2Y12 inhibitors used in PCI:^[1]
The following table shows the loading and maintenance dose of oral antiplatelet drug in patients who are undergoing PCI:^[9]^[10]^[11]^[12]^[13]^[14]^[15]^[16]^[17]

Medication	Loading Dose	Maintanance Dose
Aspirin	162-325 mg (can be chewed to achieve faster action)	75-100 mg daily
Clopidogrel	600 mg (a lower loading dose of 300 mg is recommended in older patients or in patients after fibrinolytic therapy)	75 mg daily
Prasugrel	60 mg	10 mg daily In patients with body weight <60 kg, a maintenance dose of 5 mg daily is recommended In patients older than 75 years old, a maintenance dose of 5 mg daily can be used if necessary
Ticagrelor	180 mg (can be chewed to achieve faster action)	90 mg twice a day

Aspirin has been used as a key agent in prevention of coronary thrombosis with balloon angioplasty and in patients with chronic vascular disease.^[18]^[19]^[20]
Due to the effects of aspirin on reducing ischemic complications after PCI its usage is recommended in the periprocedural period.^[21]
Among the medications above, clopidogrel is the least potent. Therefore, a longer duration after the loading dose is required to start its effect on platelet inhibition.
Based on a clinical trial (The CREDO), a loading dose of clopidogrel in addition to treatment up to 9 months after elective PCI are able to reduce many complications such as MI, stroke, and death.^[8] Furthermore, this study showed that there is a trend in further decreasing the ischemic events and complications when a preloading dose of 300 mg clopidogrel was administered more than 3 hours before PCI. However, a 600 mg loading dose is preferred due to a shorter time to platelet inhibition.
Based on 2021 ACA revascularization guideline, it is recommended that patients receive a loading dose of these medications either before PCI or otherwise during PCI.^[1]
A trial named PLATO (Trial to Assess The Study of Platelet Inhibition and Patient Outcomes) suggests that lower doses of aspirin (less than 100 mg) should be used for patients treated with ticagrelor.^[16]
As two trials (TRITON-TIMI-38 and PLATO) showed, prasugrel and Ticagrelor are more effective in reducing the rate of death from vascular causes, MI, and stroke compared to clopidogrel. Furthermore, these agents were associated with a lower rate of stent thrombosis. ^[22]^[16]
TRITON-TIMI-38 and PLATO trials demonstrated that the non-CABG major bleeding was higher with prasugrel.^[22]^[16] Therefore, usage of prasugrel due to higher rate of bleeding should be done with caution in older patients.
The TRITON study reported no net benefit of prasugrel compared with clopidogrel among patients with low body weight (<60 kg) or those older than 75 years old. Based on 2021 ACA revascularization guideline, treatment with prasugrel should be cautious in patients weighing less than 60 kg or in patients older than 75 years old. Furthermore, this study demonstrated the net harm with using prasugrel in patients with previous transient ischemic attack or cerebrovascular accident. Therefore, prasugrel is contraindicated in patients with a history of transient ischemic attack or stroke.^[22]

Intravenous Antiplatelets

The following table shows the loading and maintenance dose of intravenous antiplatelet drug in patients who are undergoing PCI:^[23]^[24]^[25]^[26]

Medication	Loading Dose	Maintanance Dose
Abciximab (glycoprotein IIb/IIIa inhibitor)	Bolus of 0.25 mg/kg	0.125 mg/kg/min infusion (maximum 10 g/min) for 12 hours
Eptifibatide (glycoprotein IIb/IIIa inhibitor)	Double bolus of 180 mg/kg (given at a 10-min interval)	2.0 mg/kg/min for up to 18 hours
Tirofiban (glycoprotein IIb/IIIa inhibitor)	Bolus of 25 mg/kg over 3 minutes	Infusion of 0.15 mg/kg/min for up to 18 hours
Cangrelor	Bolus of 30 mg/kg	Infusion 4 mg/kg/min for at least 2 hours or duration of the procedure, whichever is longer

Cangrelor is a potent intravenous P2Y12 inhibitor with several characteristics, such as being a direct, reversible, and short-acting medication that has a rapid onset with a rapid restoration (within 1 hour of discontinuation) of platelet function.^[1] These features of cangrelor, make it a predictable, rapid and profound platele inhibitor.
Cangrelor is an effective treatment in preventing stent thrombosis, especially in the following patients:^[1]
- In patients who did not received any pretreatment with a P2Y12 inhibitor.
- In patients whose absorption of oral medications may be inhibited.
- In patients who are unable to take oral medications.
A trial, named CHAMPION (Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), investigated the effect of cangrelor in comparison to clopidogrel.^[27]^[26]^[28] These investigations did not show any reduction in the primary outcomes such as death, MI, and ischemia-driven revascularization at 48 hours with cangrelor. However, cangrelor resulted in a reduction in prespecified secondary outcomes of stent thrombosis and death. ^[27]
On the other hand, a pooled patient-level meta-analysis] of the CHAMPION trials demonstrated a lower rate of the composite endpoint of death, MI, ischemia-driven revascularization, or stent thrombosis at 48 hours with cangrelor than with clopidogrel.^[29]
Cangrelor treatment has been associated with a 41% reduction in stent thrombosis.^[29]
Although CHAMPION trials did not show any differences in major bleeding between cangrelor and clopidogrel, minor bleeding was more frequent in the cangrelor group.^[29]

Glycoprotein IIb/IIIa Receptor Inhibitors

Glycoprotein IIb/IIIa receptor inhibitors are direct antiplatelet agents that target the glycoprotein IIb/IIIa, an integrin complex found on platelets.^[1]
Numerous clinical trials have been done in the setting of glycoprotein IIb/IIIa inhibitors among ACS patients prior to the use of potent P2Y12 inhibitors or before routine stenting.^[30]^[31] However, benefits of glycoprotein IIb/IIIa receptor inhibitors have been diminished in the era of shorter revascularization times and use of potent dual antiplatelet therapy (DAPT).^[30]^[32]
Based on the 2021 ACA Revascularization Guideline, glycoprotein IIb/IIIa inhibitors could be reserved for patients with a large thrombus burden, no-reflow or slow flow attributable to distal embolization of thrombus.^[1]
Ischemic events did not reduce after treatment with a glycoprotein IIb/IIIa receptor inhibitor and a clopidogrel load in patients with stable ischemic heart disease.^[33]^[34]
ISAR-REACT (iNtra- coronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) trial showed a similar outcome in a group that received abciximab and a 600mg loading dose of clopidogrel and another group that only received clopidogrel.^[33] Furthermore, major bleeding was not significantly different among the two groups. Nevertheless, severe thrombocytopenia was significantly higher in the abciximab group.^[33]
A subgroup analysis of the ESPRIT (Enhance Suppression of the Platelet IIB/IIIA receptor with Integrilin Therapy) trial did not revealed any benefit in the primary endpoint of death, MI, urgent target-vessel revascularization, and thrombotic bailout with eptifibatide at 48 hours among patients who undergone PCI for stable angina.^[35]

Antiplatelet Therapy In Patients Who Were Treated With Fibrinolytic Therapy

Risk of bleeding and ischemia is elevated in STEMI patients who had been treated with fibrinolytics and are planned to undergo PCI.^[1]
Clopidogrel is the only medication that has been studied in patients immediately after the administration of fibrinolytic therapy.
Based on the CLARITY (Clopidogrel as Adjunctive Reperfusion Therapy) trial, clopidogrel was studied in conjunction with fibrinolytic therapy which led to 46% lower rate of cardiovascular death, recurrent MI and stroke within the 30 days after PCI with an unchanged rate of minor and major bleedings.^[13]
However, there is some evidence associated with greater inhibition of platelet reactivity when ticagrelor is used compared with clopidogrel.^[36]
Although PLATO trial demonstrated superiority of ticagrelor over clopidogrel in patients who received fibrinolytic therapy, there are limited data regarding the safety of ticagrelor treatment immediately after fibrinolytic therapy.^[1]
Furthermore, another trial (The TREAT) showed no inferiority of ticagrelor over clopidogrel regarding TIMI major bleeding, fatal bleeding, and intracranial bleeding.^[37]

2021 ACA Revascularization Guideline

Class 1 Recommendation, Level of Evidence: ‌B-R^[1]^[18]^[19]^[20]^[13]^[22]^[3]^[38]^[39]^[40]^[41]^[42]^[16]^[43]
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]^[13]^[38]^[41]^[43]^[44]^[8]^[12]
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]^[45]^[30]
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]^[22]^[16]^[15]^[27]^[26]^[29]
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]^[33]^[34]^[35]
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.

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)^[46]

2011 AHA guidelines recommend the use of antiplatelet therapy aspirin (Level of Evidence: B) and P2Y12 receptor inhibitor (clopidogrel, prasugrel and ticagrelor) (Level of Evidence: A) to support PCI in patients with ACS. Few randomised trials have been conducted showing comparison of clopidogrel with aspirin and other P2Y12 inhibitors (prasugrel and ticagrelor) in terms of clinical benefit and risk of bleeding when given in patients undergoing PCI.^[47]^[13]^[48]^[22]^[16] However, there is limited data comparing new P2Y12 receptor inhibitors (prasugrel and ticagrelor) for downstream and upstream therapy in patients undergoing PCI with non ST elevation MI in terms of clinical benefit and adverse effects. Hence, a new large scale randomised open label trial called DUBIUS is in process in Italy comparing two new P2Y12 inhibitors prasugrel and ticagrelor for pretreatment in patients with non ST elevation MI undergoing PCI. It is a trial designed for superiority comparing downstream therapy over upstream therapy in terms of NACE (net adverse cardaic effect) and risk of major bleeding (BARC 3, 4 and 5). Another endpoint considered in the trial is non inferiority comparison between prasugrel and ticagrelor in terms of potency of the drug for clinical benefit and NACE.

Oral Antiplatelet Therapy (DO NOT EDIT)^[46]

Class I
"1. Patients already taking daily aspirin therapy should take 81 mg to 325 mg before PCI.^[49]^[10]^[50] (Level of Evidence: B)"
"2. Patients not on aspirin therapy should be given non-enteric aspirin 325 mg before PCI.^[49]^[50] (Level of Evidence: B)"
"3. After PCI, use of aspirin should be continued indefinitely.^[40]^[18]^[20]^[51] (Level of Evidence: A)"
"4. A loading dose of a P2Y12 receptor inhibitor should be given to patients undergoing PCI with stenting.^[47]^[13]^[48]^[22]^[16] (Level of Evidence: A) Options include: a. Clopidogrel 600 mg (ACS and non-ACS patients).^[47]^[47]^[13]^[48]^[22]^[16]^[13]^[48](Level of Evidence: B) b. Prasugrel 60 mg (ACS patients).^[47]^[13]^[48]^[22]^[16]^[22] (Level of Evidence: B) c. Ticagrelor 180 mg (ACS patients).^[16] (Level of Evidence: B)"
"5. The loading dose of clopidogrel for patients undergoing PCI after fibrinolytic therapy should be 300 mg within 24 hours and 600 mg more than 24 hours after receiving fibrinolytic therapy.^[13]^[52] (Level of Evidence: C)"
"6. Patients should be counseled on the need for and risks of dual antiplatelet therapy (DAPT) before placement of intra-coronary stents, especially drug eluting stents (DES), and alternative therapies should be pursued if patients are unwilling or unable to comply with the recommended duration of dual antiplatelet therapy.^[53] (Level of Evidence: C)"
"7. The duration of P2Y12 receptor inhibitor therapy after stent implantation should generally be as follows: a. In patients receiving a stent (bare metal stent (BMS) or drug eluting stent (DES)) during PCI for ACS, P2Y12 receptor inhibitor therapy should be given for at least 12 months. Options include clopidogrel 75 mg daily ^[14],prasugrel 10 mg daily ^[22], and ticagrelor 90 mg twice daily.^[16] (Level of Evidence: B) b. In patients receiving drug eluting stent (DES) for a non-ACS indication, clopidogrel 75 mg daily should be given for at least 12 months if patients are not at high risk of bleeding.^[53]^[54]^[55] (Level of Evidence: B) c. In patients receiving bare metal stent (BMS) for a non-ACS indication, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks).^[53]^[8] (Level of Evidence: B)"

Class III (Harm)
"1. Prasugrel should not be administered to patients with a prior history of stroke or transient ischemic attack.^[22] (Level of Evidence: B)"

Class IIa
"1. After PCI, it is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses.^[10]^[56]^[57]^[11]^[58] (Level of Evidence: B)"
"2. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 receptor inhibitor therapy after stent implantation, earlier discontinuation (e.g.,less than 12 months) of P2Y12 receptor inhibitor therapy is reasonable. (Level of Evidence: C)"

Class IIb
"1. Continuation of dual antiplatelet therapy (DAPT) beyond 12 months may be considered in patients undergoing drug eluting stent (DES) implantation.^[22]^[16] (Level of Evidence: C)"

Dual Antiplatelet Therapy Compliance and Stent Thrombosis (DO NOT EDIT) ^[46]

Class III (Harm)
"1. PCI with coronary stenting (BMS or DES) should not be performed if the patient is not likely to be able to tolerate and comply with dual antiplatelet therapy (DAPT) for the appropriate duration of treatment based on the type of stent implanted. ^[53]^[9]^[59]^[60](Level of Evidence: B)"

References

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↑ Brar SS, Kim J, Brar SK, Zadegan R, Ree M, Liu IL, Mansukhani P, Aharonian V, Hyett R, Shen AY (2008). "Long-term outcomes by clopidogrel duration and stent type in a diabetic population with de novo coronary artery lesions". Journal of the American College of Cardiology. 51 (23): 2220–7. doi:10.1016/j.jacc.2008.01.063. PMID 18534267. Retrieved 2011-12-13. Unknown parameter |month= ignored (help)
↑ Eisenstein EL, Anstrom KJ, Kong DF, Shaw LK, Tuttle RH, Mark DB, Kramer JM, Harrington RA, Matchar DB, Kandzari DE, Peterson ED, Schulman KA, Califf RM (2007). "Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation". JAMA : the Journal of the American Medical Association. 297 (2): 159–68. doi:10.1001/jama.297.2.joc60179. PMID 17148711. Retrieved 2011-12-13. Unknown parameter |month= ignored (help)
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↑ Mauri L, Hsieh WH, Massaro JM, Ho KK, D'Agostino R, Cutlip DE (2007). "Stent thrombosis in randomized clinical trials of drug-eluting stents". The New England Journal of Medicine. 356 (10): 1020–9. doi:10.1056/NEJMoa067731. PMID 17296821. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
↑ McFadden EP, Stabile E, Regar E, Cheneau E, Ong AT, Kinnaird T, Suddath WO, Weissman NJ, Torguson R, Kent KM, Pichard AD, Satler LF, Waksman R, Serruys PW (2004). "Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy". Lancet. 364 (9444): 1519–21. doi:10.1016/S0140-6736(04)17275-9. PMID 15500897. Retrieved 2011-12-06.

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[pmid11419426-30] 30.0 ^30.1 ^30.2 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

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[pmid8598866-40] 40.0 ^40.1 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.

[pmid10318654-41] 41.0 ^41.1 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.

[pmid10966552-42] 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.

[pmid10673248-43] 43.0 ^43.1 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.

[pmid10931801-44] 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.

[pmid22447888-45] 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.

[pmid22070837-46] 46.0 ^46.1 ^46.2 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter |month= ignored (help)

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 {{CMG}} {{AE}}{{AA}} {{Anahita}}
 ==Overview==
+[[Dual anti-platelet therapy]] ([[aspirin]] and [[oral]] [[P2Y12 inhibitors]]) is the main [[therapy]] for the [[prevention]] of [[thrombus|thrombotic]] [[complications]] in [[patients]] with [[PCI]]. It has been recommended to avoid routine [[P2Y12 inhibitor]] [[treatment]] in [[patients]] with [[stable angina]] whose [[coronary]] [[anatomy]] is unknown. [[Antiplatelet]] [[medications]] are divided into those which can be used [[oral|orally]] or [[intravenous|intravenously]]. [[Clopidogrel]], [[ticagrelor]] and [[prasugrel]] are the common present-day [[oral]] [[P2Y12 inhibitors]] with different [[dose|dosage]], characteristics and considerations. On the other hand, [[aspirin]] has been used as a key agent in [[prevention]] of [[coronary]] [[thrombosis]] with [[balloon angioplasty]] and in [[patients]] with [[chronic]] [[vascular disease]]. Usage of [[aspirin]] is recommended in the [[surgery|periprocedural]] period due to its effect on reducing [[ischemia|ischemic]] [[complications]] after [[PCI]]. [[Intravenous]] [[antiplatelets]] such as [[abciximab]], [[eptifibatide]], [[tirofiban]], and [[cangrelor]] have been studied in different [[clinical trials]]. Among these [[medications]] only [[cangrelor]] is a [[P2Y12]] inhibitor and the other ones are [[glycoprotein IIb/IIIa inhibitor]]. [[Antiplatelet]] [[therapy]] in [[STEMI]] [[patients]] who had been [[treatment|treated]] with [[fibrinolytics]] who are undergoing [[PCI]] is high risk due to higher rate of [[bleeding]] and [[ischemia]]. However, [[clopidogrel]] was studied in conjunction with [[fibrinolytic therapy]] and led to 46% lower rate of [[Circulatory system|cardiovascular]] death, recurrent [[MI]] and [[stroke]] within the 30 days after [[PCI]] with an unchanged rate of minor and major [[bleeding]].
 ==Antiplatelet Therapy to Support PCI==
 *[[Dual anti-platelet therapy]] ([[aspirin]] and [[oral]] [[P2Y12 inhibitors]]) is the main [[therapy]] for the [[prevention]] of thrombotic complications in [[patients]] with [[PCI]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
-*[[Aspirin]] has been used as a key agent in [[prevention]] of [[coronary]] [[thrombosis]] with [[balloon angioplasty]] and in [[patients]] with [[chronic]] [[vascular disease]].<ref name="pmid11786451">{{cite journal| author=Antithrombotic Trialists' Collaboration| title=Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. | journal=BMJ | year= 2002 | volume= 324 | issue= 7329 | pages= 71-86 | pmid=11786451 | doi=10.1136/bmj.324.7329.71 | pmc=64503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11786451  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=12093204 Review in: ACP J Club. 2002 Jul-Aug;137(1):5] </ref><ref name="pmid8298418">{{cite journal| author=| title=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. | journal=BMJ | year= 1994 | volume= 308 | issue= 6921 | pages= 81-106 | pmid=8298418 | doi= | pmc=2539220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8298418  }} </ref><ref name="pmid19482214">{{cite journal| author=Antithrombotic Trialists' (ATT) Collaboration. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J | display-authors=etal| title=Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. | journal=Lancet | year= 2009 | volume= 373 | issue= 9678 | pages= 1849-60 | pmid=19482214 | doi=10.1016/S0140-6736(09)60503-1 | pmc=2715005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19482214  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=19755350 Review in: Ann Intern Med. 2009 Sep 15;151(6):JC3-4, JC3-5]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=19949174 Review in: Evid Based Med. 2009 Dec;14(6):172-3] </ref>
+*There is no evidence to support routine [[treatment|pretreatment]] with a [[P2Y12 inhibitor]] in [[patients]] with [[stable angina]] before [[coronary angiography]] when the [[coronary]] [[anatomy]] is not known.<ref name="pmid18441320">{{cite journal| author=Widimsky P, Motovská Z, Simek S, Kala P, Pudil R, Holm F | display-authors=etal| title=Clopidogrel pre-treatment in stable angina: for all patients > 6 h before elective coronary angiography or only for angiographically selected patients a few minutes before PCI? A randomized multicentre trial PRAGUE-8. | journal=Eur Heart J | year= 2008 | volume= 29 | issue= 12 | pages= 1495-503 | pmid=18441320 | doi=10.1093/eurheartj/ehn169 | pmc=2429977 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18441320  }} </ref><ref name="pmid25175921">{{cite journal| author=Montalescot G, van 't Hof AW, Lapostolle F, Silvain J, Lassen JF, Bolognese L | display-authors=etal| title=Prehospital ticagrelor in ST-segment elevation myocardial infarction. | journal=N Engl J Med | year= 2014 | volume= 371 | issue= 11 | pages= 1016-27 | pmid=25175921 | doi=10.1056/NEJMoa1407024 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25175921  }} </ref><ref name="pmid21920970">{{cite journal| author=Dörler J, Edlinger M, Alber HF, Altenberger J, Benzer W, Grimm G | display-authors=etal| title=Clopidogrel pre-treatment is associated with reduced in-hospital mortality in primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. | journal=Eur Heart J | year= 2011 | volume= 32 | issue= 23 | pages= 2954-61 | pmid=21920970 | doi=10.1093/eurheartj/ehr360 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21920970  }} </ref><ref name="pmid22186968">{{cite journal| author=Zeymer U, Arntz HR, Mark B, Fichtlscherer S, Werner G, Schöller R | display-authors=etal| title=Efficacy and safety of a high loading dose of clopidogrel administered prehospitally to improve primary percutaneous coronary intervention in acute myocardial infarction: the randomized CIPAMI trial. | journal=Clin Res Cardiol | year= 2012 | volume= 101 | issue= 4 | pages= 305-12 | pmid=22186968 | doi=10.1007/s00392-011-0393-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22186968  }} </ref><ref name="pmid23991622">{{cite journal| author=Montalescot G, Bolognese L, Dudek D, Goldstein P, Hamm C, Tanguay JF | display-authors=etal| title=Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. | journal=N Engl J Med | year= 2013 | volume= 369 | issue= 11 | pages= 999-1010 | pmid=23991622 | doi=10.1056/NEJMoa1308075 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23991622  }} </ref><ref name="pmid32882390">{{cite journal| author=Tarantini G, Mojoli M, Varbella F, Caporale R, Rigattieri S, Andò G | display-authors=etal| title=Timing of Oral P2Y12 Inhibitor Administration in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. | journal=J Am Coll Cardiol | year= 2020 | volume= 76 | issue= 21 | pages= 2450-2459 | pmid=32882390 | doi=10.1016/j.jacc.2020.08.053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32882390  }} </ref> This statement is important since a considerable proportion of [[patients]] who has been sent for [[PCI]] still may require [[CABG]] and [[treatment|pretreatment]] with [[P2Y12 inhibitor]] will delay the [[surgery]].<ref name="pmid12435254">{{cite journal| author=Steinhubl SR, Berger PB, Mann JT, Fry ET, DeLago A, Wilmer C | display-authors=etal| title=Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 288 | issue= 19 | pages= 2411-20 | pmid=12435254 | doi=10.1001/jama.288.19.2411 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12435254  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=12841706 Review in: ACP J Club. 2003 Jul-Aug;139(1):2] </ref>
+===Oral Antiplatelets===
 *The following are the contemporary [[oral]] [[P2Y12 inhibitors]] used in [[PCI]]:<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
 **[[Clopidogrel]]
 **[[Ticagrelor]]
 **[[Prasugrel]]
-*Based on 2021 ACA revascularization guideline, it is recommended that [[patients]] receive a [[dose|loading dose]] of these [[medications]] either before [[PCI]] or otherwise during [[PCI]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+*The following table shows the [[dose|loading]] and [[dose|maintenance dose]] of [[oral]] [[antiplatelet drug]] in [[patients]] who are undergoing [[PCI]]:<ref name="pmid9834303">{{cite journal| author=Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK | display-authors=etal| title=A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 23 | pages= 1665-71 | pmid=9834303 | doi=10.1056/NEJM199812033392303 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9834303  }} </ref><ref name="pmid18819961">{{cite journal| author=Jolly SS, Pogue J, Haladyn K, Peters RJ, Fox KA, Avezum A | display-authors=etal| title=Effects of aspirin dose on ischaemic events and bleeding after percutaneous coronary intervention: insights from the PCI-CURE study. | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 8 | pages= 900-7 | pmid=18819961 | doi=10.1093/eurheartj/ehn417 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18819961  }} </ref><ref name="pmid15877994">{{cite journal| author=Serebruany VL, Steinhubl SR, Berger PB, Malinin AI, Baggish JS, Bhatt DL | display-authors=etal| title=Analysis of risk of bleeding complications after different doses of aspirin in 192,036 patients enrolled in 31 randomized controlled trials. | journal=Am J Cardiol | year= 2005 | volume= 95 | issue= 10 | pages= 1218-22 | pmid=15877994 | doi=10.1016/j.amjcard.2005.01.049 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15877994  }} </ref><ref name="pmid16260639">{{cite journal| author=von Beckerath N, Taubert D, Pogatsa-Murray G, Schömig E, Kastrati A, Schömig A| title=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. | journal=Circulation | year= 2005 | volume= 112 | issue= 19 | pages= 2946-50 | pmid=16260639 | doi=10.1161/CIRCULATIONAHA.105.559088 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16260639  }} </ref><ref name="pmid16143698">{{cite journal| author=Sabatine MS, Cannon CP, Gibson CM, López-Sendón JL, Montalescot G, Theroux P | display-authors=etal| title=Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. | journal=JAMA | year= 2005 | volume= 294 | issue= 10 | pages= 1224-32 | pmid=16143698 | doi=10.1001/jama.294.10.1224 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143698  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=16539344 Review in: ACP J Club. 2006 Mar-Apr;144(2):29] </ref><ref name="pmid11520521">{{cite journal| author=Mehta SR, Yusuf S, Peters RJ, Bertrand ME, Lewis BS, Natarajan MK | display-authors=etal| title=Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. | journal=Lancet | year= 2001 | volume= 358 | issue= 9281 | pages= 527-33 | pmid=11520521 | doi=10.1016/s0140-6736(01)05701-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11520521  }} </ref><ref name="pmid19249633">{{cite journal| author=Montalescot G, Wiviott SD, Braunwald E, Murphy SA, Gibson CM, McCabe CH | display-authors=etal| title=Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. | journal=Lancet | year= 2009 | volume= 373 | issue= 9665 | pages= 723-31 | pmid=19249633 | doi=10.1016/S0140-6736(09)60441-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19249633  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=19528555 Review in: Ann Intern Med. 2009 Jun 16;150(12):JC6-10] </ref><ref name="pmid19717846">{{cite journal| author=Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C | display-authors=etal| title=Ticagrelor versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 11 | pages= 1045-57 | pmid=19717846 | doi=10.1056/NEJMoa0904327 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19717846  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=20008753 Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4] </ref><ref name="pmid32687741">{{cite journal| author=Menichelli M, Neumann FJ, Ndrepepa G, Mayer K, Wöhrle J, Bernlochner I | display-authors=etal| title=Age- and Weight-Adapted Dose of Prasugrel Versus Standard Dose of Ticagrelor in Patients With Acute Coronary Syndromes : Results From a Randomized Trial. | journal=Ann Intern Med | year= 2020 | volume= 173 | issue= 6 | pages= 436-444 | pmid=32687741 | doi=10.7326/M20-1806 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32687741  }} </ref>
-*The following table shows the [[dose|loading]] and [[dose|maintenance dose]] of [[oral]] [[antiplatelet drug]] in [[patients]] who are undergoing [[PCI]]:
+<br>
 {| style="border: 2px solid #4479BA; align="left"
 ! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|[[Medication]]}}
@@ Line 19: / Line 21: @@
 |-
 | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Aspirin]]
-| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Clopidogrel]]
-| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prasugrel]]
-| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Ticagrelor]]
-|-
 | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 162-325 mg (can be chewed to achieve faster action)
-| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 600 mg (a lower [[dose|loading dose]] of 300 mg is recommended in [[patients]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 75-100 mg daily
-after [[fibrinolytic therapy]]
-| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 60 mg
-| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 180 mg (can be chewed to achieve faster action)
 |-
-| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 75-100 mg daily
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Clopidogrel]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 600 mg (a lower [[dose|loading dose]] of 300 mg is recommended in older [[patients]] or in [[patients]] after [[fibrinolytic therapy]])
 | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 75 mg daily
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Prasugrel]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 60 mg
 | style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 10 mg daily
 *In [[patients]] with body weight <60 kg, a [[dose|maintenance dose]] of 5 mg daily is recommended
 *In [[patients]] [[old age|older]] than 75 years old, a [[dose|maintenance dose]] of 5 mg daily can be used if necessary
-| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 90 mg twice a day
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Ticagrelor]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 180 mg (can be chewed to achieve faster action)
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 90 mg twice a day
+|-
+|}
+*[[Aspirin]] has been used as a key agent in [[prevention]] of [[coronary]] [[thrombosis]] with [[balloon angioplasty]] and in [[patients]] with [[chronic]] [[vascular disease]].<ref name="pmid11786451">{{cite journal| author=Antithrombotic Trialists' Collaboration| title=Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. | journal=BMJ | year= 2002 | volume= 324 | issue= 7329 | pages= 71-86 | pmid=11786451 | doi=10.1136/bmj.324.7329.71 | pmc=64503 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11786451  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=12093204 Review in: ACP J Club. 2002 Jul-Aug;137(1):5] </ref><ref name="pmid8298418">{{cite journal| author=| title=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. | journal=BMJ | year= 1994 | volume= 308 | issue= 6921 | pages= 81-106 | pmid=8298418 | doi= | pmc=2539220 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8298418  }} </ref><ref name="pmid19482214">{{cite journal| author=Antithrombotic Trialists' (ATT) Collaboration. Baigent C, Blackwell L, Collins R, Emberson J, Godwin J | display-authors=etal| title=Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. | journal=Lancet | year= 2009 | volume= 373 | issue= 9678 | pages= 1849-60 | pmid=19482214 | doi=10.1016/S0140-6736(09)60503-1 | pmc=2715005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19482214  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=19755350 Review in: Ann Intern Med. 2009 Sep 15;151(6):JC3-4, JC3-5]  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=19949174 Review in: Evid Based Med. 2009 Dec;14(6):172-3] </ref>
+*Due to the effects of [[aspirin]] on reducing [[ischemia|ischemic]] [[complications]] after [[PCI]] its usage is recommended in the [[surgery|periprocedural]] period.<ref name="pmid2967433">{{cite journal| author=Schwartz L, Bourassa MG, Lespérance J, Aldridge HE, Kazim F, Salvatori VA | display-authors=etal| title=Aspirin and dipyridamole in the prevention of restenosis after percutaneous transluminal coronary angioplasty. | journal=N Engl J Med | year= 1988 | volume= 318 | issue= 26 | pages= 1714-9 | pmid=2967433 | doi=10.1056/NEJM198806303182603 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2967433  }} </ref>
+*Among the [[medications]] above, [[clopidogrel]] is the least potent. Therefore, a longer duration after the [[dose|loading dose]] is required to start its effect on [[platelet]] inhibition.
+*Based on a [[clinical trial]] (The CREDO), a [[dose|loading dose]] of [[clopidogrel]] in addition to [[treatment]] up to 9 months after elective [[PCI]] are able to reduce many [[complications]] such as [[MI]], [[stroke]], and death.<ref name="pmid12435254">{{cite journal| author=Steinhubl SR, Berger PB, Mann JT, Fry ET, DeLago A, Wilmer C | display-authors=etal| title=Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. | journal=JAMA | year= 2002 | volume= 288 | issue= 19 | pages= 2411-20 | pmid=12435254 | doi=10.1001/jama.288.19.2411 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12435254  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=12841706 Review in: ACP J Club. 2003 Jul-Aug;139(1):2] </ref> Furthermore, this study showed that there is a trend in further decreasing the [[ischemia|ischemic events]] and [[complications]] when a preloading dose of 300 mg [[clopidogrel]] was administered more than 3 hours before [[PCI]]. However, a 600 mg [[dose|loading dose]] is preferred due to a shorter time to [[platelet]] inhibition.
+*Based on 2021 ACA revascularization guideline, it is recommended that [[patients]] receive a [[dose|loading dose]] of these [[medications]] either before [[PCI]] or otherwise during [[PCI]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+*A [[Clinical trial|trial]] named PLATO (Trial to Assess The Study of Platelet Inhibition and Patient Outcomes) suggests that lower [[dose|doses]] of [[aspirin]] (less than 100 mg) should be used for [[patients]] treated with [[ticagrelor]].<ref name="pmid19717846">{{cite journal| author=Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C | display-authors=etal| title=Ticagrelor versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 11 | pages= 1045-57 | pmid=19717846 | doi=10.1056/NEJMoa0904327 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19717846  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=20008753 Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4] </ref>
+*As two [[clinical trial|trials]] (TRITON-TIMI-38 and PLATO) showed, [[prasugrel]] and [[Ticagrelor]] are more effective in reducing the rate of death from vascular causes, [[MI]], and [[stroke]] compared to [[clopidogrel]]. Furthermore, these agents were associated with a lower rate of [[stent]] [[thrombosis]]. <ref name="pmid17982182">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S | display-authors=etal| title=Prasugrel versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2001-15 | pmid=17982182 | doi=10.1056/NEJMoa0706482 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17982182  }} </ref><ref name="pmid19717846">{{cite journal| author=Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C | display-authors=etal| title=Ticagrelor versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 11 | pages= 1045-57 | pmid=19717846 | doi=10.1056/NEJMoa0904327 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19717846  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=20008753 Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4] </ref>
+*TRITON-TIMI-38 and PLATO [[clinical trial|trials]] demonstrated that the non-[[CABG]] major [[bleeding]] was higher with [[prasugrel]].<ref name="pmid17982182">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S | display-authors=etal| title=Prasugrel versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2001-15 | pmid=17982182 | doi=10.1056/NEJMoa0706482 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17982182  }} </ref><ref name="pmid19717846">{{cite journal| author=Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C | display-authors=etal| title=Ticagrelor versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 11 | pages= 1045-57 | pmid=19717846 | doi=10.1056/NEJMoa0904327 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19717846  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=20008753 Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4] </ref> Therefore, usage of [[prasugrel]] due to higher rate of [[bleeding]] should be done with caution in [[old age|older]] [[patients]].
+*The TRITON study reported no net benefit of [[prasugrel]] compared with [[clopidogrel]] among [[patients]] with [[Body mass index|low body weight]] (<60 kg) or those older than 75 years old. Based on 2021 ACA revascularization guideline, [[treatment]] with [[prasugrel]] should be cautious in [[patients]] weighing less than 60 kg or in [[patients]] older than 75 years old. Furthermore, this study demonstrated the net harm with using [[prasugrel]] in [[patients]] with previous [[transient ischemic attack]] or [[cerebrovascular accident]]. Therefore, [[prasugrel]] is [[contraindicated]] in [[patients]] with a history of [[transient ischemic attack]] or [[stroke]].<ref name="pmid17982182">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S | display-authors=etal| title=Prasugrel versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2001-15 | pmid=17982182 | doi=10.1056/NEJMoa0706482 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17982182  }} </ref>
+===Intravenous Antiplatelets===
+*The following table shows the [[dose|loading]] and [[dose|maintenance dose]] of [[intravenous]] [[antiplatelet drug]] in [[patients]] who are undergoing [[PCI]]:<ref name="pmid11919304">{{cite journal| author=Stone GW, Grines CL, Cox DA, Garcia E, Tcheng JE, Griffin JJ | display-authors=etal| title=Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. | journal=N Engl J Med | year= 2002 | volume= 346 | issue= 13 | pages= 957-66 | pmid=11919304 | doi=10.1056/NEJMoa013404 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11919304  }} </ref><ref name="pmid19332455">{{cite journal| author=Giugliano RP, White JA, Bode C, Armstrong PW, Montalescot G, Lewis BS | display-authors=etal| title=Early versus delayed, provisional eptifibatide in acute coronary syndromes. | journal=N Engl J Med | year= 2009 | volume= 360 | issue= 21 | pages= 2176-90 | pmid=19332455 | doi=10.1056/NEJMoa0901316 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19332455  }} </ref><ref name="pmid18375998">{{cite journal| author=Valgimigli M, Campo G, Percoco G, Bolognese L, Vassanelli C, Colangelo S | display-authors=etal| title=Comparison of angioplasty with infusion of tirofiban or abciximab and with implantation of sirolimus-eluting or uncoated stents for acute myocardial infarction: the MULTISTRATEGY randomized trial. | journal=JAMA | year= 2008 | volume= 299 | issue= 15 | pages= 1788-99 | pmid=18375998 | doi=10.1001/jama.299.15.joc80026 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18375998  }} </ref><ref name="pmid23473369">{{cite journal| author=Bhatt DL, Stone GW, Mahaffey KW, Gibson CM, Steg PG, Hamm CW | display-authors=etal| title=Effect of platelet inhibition with cangrelor during PCI on ischemic events. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 14 | pages= 1303-13 | pmid=23473369 | doi=10.1056/NEJMoa1300815 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23473369  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=23778929 Review in: Ann Intern Med. 2013 Jun 18;158(12):JC5] </ref>
+<br>
+{| style="border: 2px solid #4479BA; align="left"
+! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|[[Medication]]}}
+! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|[[dose|Loading Dose]]}}
+! style="width: 300px; background: #4479BA;" | {{fontcolor|#FFF|[[dose|Maintanance Dose]]}}
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Abciximab]] ([[glycoprotein IIb/IIIa inhibitor]])
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bolus]] of 0.25 mg/kg
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 0.125 mg/kg/min [[infusion]] (maximum 10 g/min) for 12 hours
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Eptifibatide]] ([[glycoprotein IIb/IIIa inhibitor]])
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bolus|Double bolus]] of 180 mg/kg (given at a 10-min interval)
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | 2.0 mg/kg/min for up to 18 hours
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Tirofiban]] ([[glycoprotein IIb/IIIa inhibitor]])
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bolus]] of 25 mg/kg over 3 minutes
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Infusion]] of 0.15 mg/kg/min for up to 18 hours
+|-
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Cangrelor]]
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Bolus]] of 30 mg/kg
+| style="padding: 0 5px; background: #F5F5F5; text-align: left;" | [[Infusion]] 4 mg/kg/min for at least 2 hours or duration of the procedure, whichever is longer
 |-
 |}
+*[[Cangrelor]] is a potent [[intravenous]] [[P2Y12]] inhibitor with several characteristics, such as being a direct, reversible, and short-acting [[medication]] that has a rapid onset with a rapid restoration (within 1 hour of discontinuation) of [[platelet]] function.<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref> These features of [[cangrelor]], make it a predictable, rapid and profound [[platele]] inhibitor.
+*[[Cangrelor]] is an effective [[treatment]] in [[prevention|preventing]] [[stent thrombosis]], especially in the following [[patients]]:<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+**In [[patients]] who did not received any [[treatment|pretreatment]] with a [[P2Y12 inhibitor]].
+**In [[patients]] whose absorption of [[oral]] [[medications]] may be inhibited.
+**In [[patients]] who are unable to take [[oral]] [[medications]].
+*A [[clinical trials |trial]], named CHAMPION (Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), investigated the effect of [[cangrelor]] in comparison to [[clopidogrel]].<ref name="pmid19915222">{{cite journal| author=Bhatt DL, Lincoff AM, Gibson CM, Stone GW, McNulty S, Montalescot G | display-authors=etal| title=Intravenous platelet blockade with cangrelor during PCI. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 24 | pages= 2330-41 | pmid=19915222 | doi=10.1056/NEJMoa0908629 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19915222  }} </ref><ref name="pmid23473369">{{cite journal| author=Bhatt DL, Stone GW, Mahaffey KW, Gibson CM, Steg PG, Hamm CW | display-authors=etal| title=Effect of platelet inhibition with cangrelor during PCI on ischemic events. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 14 | pages= 1303-13 | pmid=23473369 | doi=10.1056/NEJMoa1300815 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23473369  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=23778929 Review in: Ann Intern Med. 2013 Jun 18;158(12):JC5] </ref><ref name="pmid19915221">{{cite journal| author=Harrington RA, Stone GW, McNulty S, White HD, Lincoff AM, Gibson CM | display-authors=etal| title=Platelet inhibition with cangrelor in patients undergoing PCI. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 24 | pages= 2318-29 | pmid=19915221 | doi=10.1056/NEJMoa0908628 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19915221  }} </ref> These investigations did not show any reduction in the primary outcomes such as death, [[MI]], and [[ischemia]]-driven [[revascularization]] at 48 hours with [[cangrelor]]. However, [[cangrelor]] resulted in a reduction in prespecified secondary outcomes of [[stent thrombosis]] and death. <ref name="pmid19915222">{{cite journal| author=Bhatt DL, Lincoff AM, Gibson CM, Stone GW, McNulty S, Montalescot G | display-authors=etal| title=Intravenous platelet blockade with cangrelor during PCI. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 24 | pages= 2330-41 | pmid=19915222 | doi=10.1056/NEJMoa0908629 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19915222  }} </ref>
+*On the other hand, a pooled [[patient]]-level [[meta-analysis]]] of the CHAMPION trials demonstrated a lower rate of the composite endpoint of death, [[MI]], [[ischemia]]-driven [[revascularization]], or [[stent thrombosis]] at 48 hours with [[cangrelor]] than with [[clopidogrel]].<ref name="pmid24011551">{{cite journal| author=Steg PG, Bhatt DL, Hamm CW, Stone GW, Gibson CM, Mahaffey KW | display-authors=etal| title=Effect of cangrelor on periprocedural outcomes in percutaneous coronary interventions: a pooled analysis of patient-level data. | journal=Lancet | year= 2013 | volume= 382 | issue= 9909 | pages= 1981-92 | pmid=24011551 | doi=10.1016/S0140-6736(13)61615-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24011551  }} </ref>
+*[[Cangrelor]] [[treatment]] has been associated with a 41% reduction in [[stent thrombosis]].<ref name="pmid24011551">{{cite journal| author=Steg PG, Bhatt DL, Hamm CW, Stone GW, Gibson CM, Mahaffey KW | display-authors=etal| title=Effect of cangrelor on periprocedural outcomes in percutaneous coronary interventions: a pooled analysis of patient-level data. | journal=Lancet | year= 2013 | volume= 382 | issue= 9909 | pages= 1981-92 | pmid=24011551 | doi=10.1016/S0140-6736(13)61615-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24011551  }} </ref>
+*Although CHAMPION trials did not show any differences in major [[bleeding]] between [[cangrelor]] and [[clopidogrel]], minor [[bleeding]] was more frequent in the [[cangrelor]] group.<ref name="pmid24011551">{{cite journal| author=Steg PG, Bhatt DL, Hamm CW, Stone GW, Gibson CM, Mahaffey KW | display-authors=etal| title=Effect of cangrelor on periprocedural outcomes in percutaneous coronary interventions: a pooled analysis of patient-level data. | journal=Lancet | year= 2013 | volume= 382 | issue= 9909 | pages= 1981-92 | pmid=24011551 | doi=10.1016/S0140-6736(13)61615-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24011551  }} </ref>
+====Glycoprotein IIb/IIIa Receptor Inhibitors====
+*[[Glycoprotein IIb/IIIa receptor inhibitors]] are direct [[Antiplatelet drug|antiplatelet agents]] that target the [[glycoprotein IIb/IIIa]], an [[integrin]] complex found on [[platelets]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+*Numerous [[clinical trials]] have been done in the setting of [[glycoprotein IIb/IIIa inhibitors]] among [[ACS]] [[patients]] prior to the use of potent [[P2Y12 inhibitors]] or before routine stenting.<ref name="pmid11419426">{{cite journal| author=Montalescot G, Barragan P, Wittenberg O, Ecollan P, Elhadad S, Villain P | display-authors=etal| title=Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. | journal=N Engl J Med | year= 2001 | volume= 344 | issue= 25 | pages= 1895-903 | pmid=11419426 | doi=10.1056/NEJM200106213442503 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11419426  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=11985430 Review in: ACP J Club. 2002 May-Jun;136(3):89] </ref><ref name="pmid9705684">{{cite journal| author=Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators| title=Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. | journal=N Engl J Med | year= 1998 | volume= 339 | issue= 7 | pages= 436-43 | pmid=9705684 | doi=10.1056/NEJM199808133390704 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9705684  }} </ref> However, benefits of [[glycoprotein IIb/IIIa receptor inhibitors]] have been diminished in the era of shorter [[revascularization]] times and use of potent [[dual antiplatelet therapy]] ([[DAPT]]).<ref name="pmid11419426">{{cite journal| author=Montalescot G, Barragan P, Wittenberg O, Ecollan P, Elhadad S, Villain P | display-authors=etal| title=Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. | journal=N Engl J Med | year= 2001 | volume= 344 | issue= 25 | pages= 1895-903 | pmid=11419426 | doi=10.1056/NEJM200106213442503 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11419426  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=11985430 Review in: ACP J Club. 2002 May-Jun;136(3):89] </ref><ref name="pmid22077909">{{cite journal| author=Kastrati A, Neumann FJ, Schulz S, Massberg S, Byrne RA, Ferenc M | display-authors=etal| title=Abciximab and heparin versus bivalirudin for non-ST-elevation myocardial infarction. | journal=N Engl J Med | year= 2011 | volume= 365 | issue= 21 | pages= 1980-9 | pmid=22077909 | doi=10.1056/NEJMoa1109596 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22077909  }} </ref>
+*Based on the 2021 ACA Revascularization Guideline, [[glycoprotein IIb/IIIa inhibitors]] could be reserved for [[patients]] with a large [[thrombus]] burden, no-reflow or slow flow attributable to distal embolization of [[thrombus]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+*[[ischemia|Ischemic events]] did not reduce after [[treatment]] with a [[glycoprotein IIb/IIIa receptor inhibitor]] and a [[clopidogrel]] load in [[patients]] with stable [[ischemic heart disease]].<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref><ref name="pmid11368699">{{cite journal| author=O'Shea JC, Hafley GE, Greenberg S, Hasselblad V, Lorenz TJ, Kitt MM | display-authors=etal| title=Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial: a randomized controlled trial. | journal=JAMA | year= 2001 | volume= 285 | issue= 19 | pages= 2468-73 | pmid=11368699 | doi=10.1001/jama.285.19.2468 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11368699  }} </ref>
+*ISAR-REACT (iNtra- coronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) [[clinical trail|trial]] showed a similar outcome in a group that received [[abciximab]] and a 600mg [[dose|loading dose]] of [[clopidogrel]] and another group that only received [[clopidogrel]].<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref> Furthermore, major [[bleeding]] was not significantly different among the two groups. Nevertheless, severe [[thrombocytopenia]] was significantly higher in the [[abciximab]] group.<ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref>
+*A subgroup analysis of the ESPRIT (Enhance Suppression of the Platelet IIB/IIIA receptor with Integrilin Therapy) [[clinical trail|trial]] did not revealed any benefit in the primary endpoint of death, [[MI]], urgent target-vessel [[revascularization]], and thrombotic bailout with eptifibatide at 48 hours among [[patients]] who undergone [[PCI]] for [[stable angina]].<ref name="pmid11145489">{{cite journal| author=ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy| title=Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. | journal=Lancet | year= 2000 | volume= 356 | issue= 9247 | pages= 2037-44 | pmid=11145489 | doi=10.1016/S0140-6736(00)03400-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11145489  }} </ref>
+===Antiplatelet Therapy In Patients Who Were Treated With Fibrinolytic Therapy===
+*Risk of [[bleeding]] and [[ischemia]] is elevated in [[STEMI]] [[patients]] who had been [[treatment|treated]] with [[fibrinolytics]] and are planned to undergo [[PCI]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+*[[Clopidogrel]] is the only [[medication]] that has been studied in [[patients]] immediately after the administration of [[fibrinolytic therapy]].
+*Based on the CLARITY (Clopidogrel as Adjunctive Reperfusion Therapy) [[clinical|trial]], [[clopidogrel]] was studied in conjunction with [[fibrinolytic therapy]] which led to 46% lower rate of [[Circulatory system|cardiovascular]] death, recurrent [[MI]] and [[stroke]] within the 30 days after [[PCI]] with an unchanged rate of minor and major [[bleedings]].<ref name="pmid16143698">{{cite journal| author=Sabatine MS, Cannon CP, Gibson CM, López-Sendón JL, Montalescot G, Theroux P | display-authors=etal| title=Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. | journal=JAMA | year= 2005 | volume= 294 | issue= 10 | pages= 1224-32 | pmid=16143698 | doi=10.1001/jama.294.10.1224 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16143698  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=16539344 Review in: ACP J Club. 2006 Mar-Apr;144(2):29] </ref>
+*However, there is some evidence associated with greater inhibition of [[platelet]] reactivity when [[ticagrelor]] is used compared with [[clopidogrel]].<ref name="pmid28938956">{{cite journal| author=Dehghani P, Lavoie A, Lavi S, Crawford JJ, Harenberg S, Zimmermann RH | display-authors=etal| title=Effects of ticagrelor versus clopidogrel on platelet function in fibrinolytic-treated STEMI patients undergoing early PCI. | journal=Am Heart J | year= 2017 | volume= 192 | issue=  | pages= 105-112 | pmid=28938956 | doi=10.1016/j.ahj.2017.07.013 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28938956  }} </ref>
+*Although PLATO [[clinical trail|trial]] demonstrated superiority of [[ticagrelor]] over [[clopidogrel]] in [[patients]] who received [[fibrinolytic therapy]], there are limited data regarding the safety of [[ticagrelor]] [[treatment]] immediately after [[fibrinolytic therapy]].<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+*Furthermore, another [[clinical trial|trial]] (The TREAT) showed no inferiority of [[ticagrelor]] over [[clopidogrel]] regarding [[TIMI]] major [[bleeding]], [[bleeding|fatal bleeding]], and [[intracranial bleeding]].<ref name="pmid29525822">{{cite journal| author=Berwanger O, Nicolau JC, Carvalho AC, Jiang L, Goodman SG, Nicholls SJ | display-authors=etal| title=Ticagrelor vs Clopidogrel After Fibrinolytic Therapy in Patients With ST-Elevation Myocardial Infarction: A Randomized Clinical Trial. | journal=JAMA Cardiol | year= 2018 | volume= 3 | issue= 5 | pages= 391-399 | pmid=29525822 | doi=10.1001/jamacardio.2018.0612 | pmc=5875327 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29525822  }} </ref>
 ==2021 ACA Revascularization Guideline ==
@@ Line 55: / Line 115: @@
 {|class="wikitable"
 |-
-| colspan="1" style="text-align:center; background:Lightblue"|Class 2b Recommendation, Level of Evidence: B-R <ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref><ref name="pmid17982182">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S | display-authors=etal| title=Prasugrel versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2001-15 | pmid=17982182 | doi=10.1056/NEJMoa0706482 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17982182  }} </ref><ref name="pmid19717846">{{cite journal| author=Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C | display-authors=etal| title=Ticagrelor versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 11 | pages= 1045-57 | pmid=19717846 | doi=10.1056/NEJMoa0904327 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19717846  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=20008753 Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4] </ref><ref name="pmid19249633">{{cite journal| author=Montalescot G, Wiviott SD, Braunwald E, Murphy SA, Gibson CM, McCabe CH | display-authors=etal| title=Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. | journal=Lancet | year= 2009 | volume= 373 | issue= 9665 | pages= 723-31 | pmid=19249633 | doi=10.1016/S0140-6736(09)60441-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19249633  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=19528555 Review in: Ann Intern Med. 2009 Jun 16;150(12):JC6-10] </ref>
+| colspan="1" style="text-align:center; background:orange"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]], Level of Evidence: ‌C-LD<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref><ref name="pmid22447888">{{cite journal| author=Stone GW, Maehara A, Witzenbichler B, Godlewski J, Parise H, Dambrink JH | display-authors=etal| title=Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial. | journal=JAMA | year= 2012 | volume= 307 | issue= 17 | pages= 1817-26 | pmid=22447888 | doi=10.1001/jama.2012.421 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22447888  }} </ref><ref name="pmid11419426">{{cite journal| author=Montalescot G, Barragan P, Wittenberg O, Ecollan P, Elhadad S, Villain P | display-authors=etal| title=Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. | journal=N Engl J Med | year= 2001 | volume= 344 | issue= 25 | pages= 1895-903 | pmid=11419426 | doi=10.1056/NEJM200106213442503 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11419426  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=11985430 Review in: ACP J Club. 2002 May-Jun;136(3):89] </ref>
+|-
+|bgcolor="orange"|[[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="wikitable"
+|-
+| colspan="1" style="text-align:center; background:Lightblue"|Class 2b Recommendation, Level of Evidence: B-R <ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref><ref name="pmid17982182">{{cite journal| author=Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S | display-authors=etal| title=Prasugrel versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 20 | pages= 2001-15 | pmid=17982182 | doi=10.1056/NEJMoa0706482 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17982182  }} </ref><ref name="pmid19717846">{{cite journal| author=Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C | display-authors=etal| title=Ticagrelor versus clopidogrel in patients with acute coronary syndromes. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 11 | pages= 1045-57 | pmid=19717846 | doi=10.1056/NEJMoa0904327 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19717846  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=20008753 Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4] </ref><ref name="pmid19249633">{{cite journal| author=Montalescot G, Wiviott SD, Braunwald E, Murphy SA, Gibson CM, McCabe CH | display-authors=etal| title=Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. | journal=Lancet | year= 2009 | volume= 373 | issue= 9665 | pages= 723-31 | pmid=19249633 | doi=10.1016/S0140-6736(09)60441-4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19249633  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=19528555 Review in: Ann Intern Med. 2009 Jun 16;150(12):JC6-10] </ref><ref name="pmid19915222">{{cite journal| author=Bhatt DL, Lincoff AM, Gibson CM, Stone GW, McNulty S, Montalescot G | display-authors=etal| title=Intravenous platelet blockade with cangrelor during PCI. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 24 | pages= 2330-41 | pmid=19915222 | doi=10.1056/NEJMoa0908629 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19915222  }} </ref><ref name="pmid23473369">{{cite journal| author=Bhatt DL, Stone GW, Mahaffey KW, Gibson CM, Steg PG, Hamm CW | display-authors=etal| title=Effect of platelet inhibition with cangrelor during PCI on ischemic events. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 14 | pages= 1303-13 | pmid=23473369 | doi=10.1056/NEJMoa1300815 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23473369  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=23778929 Review in: Ann Intern Med. 2013 Jun 18;158(12):JC5] </ref><ref name="pmid24011551">{{cite journal| author=Steg PG, Bhatt DL, Hamm CW, Stone GW, Gibson CM, Mahaffey KW | display-authors=etal| title=Effect of cangrelor on periprocedural outcomes in percutaneous coronary interventions: a pooled analysis of patient-level data. | journal=Lancet | year= 2013 | volume= 382 | issue= 9909 | pages= 1981-92 | pmid=24011551 | doi=10.1016/S0140-6736(13)61615-3 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24011551  }} </ref>
 |-
-| bgcolor="lightblue"|Using [[ticagrelor]] or [[prasugrel]] is preferred to [[clopidogrel]] in order to decrease [[ischemia|ischemic events]] (including [[stent thrombosis]]) in [[ACS]] [[patients]] undergoing [[PCI]].
+| bgcolor="lightblue"|1. Using [[ticagrelor]] or [[prasugrel]] is preferred to [[clopidogrel]] in order to decrease [[ischemia|ischemic events]] (including [[stent thrombosis]]) in [[ACS]] [[patients]] undergoing [[PCI]].
+. [[Intravenous]] [[cangrelor]] is recommended in order to reduce [[surgery|periprocedural]] [[ischemia|ischemic events]] among [[P2Y12 inhibitor]] naïve [[patients]] who are undergoing [[PCI]].
 |}
@@ Line 68: / Line 137: @@
 {|class="wikitable"
 |-
-| colspan="1" style="text-align:center; background:lightpink"|Class 3 Recommendation: HARM, Level of Evidence: B-R<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref>
+| colspan="1" style="text-align:center; background:lightpink"|Class 3 Recommendation: HARM, Level of Evidence: B-R<ref name="pmid34895950">{{cite journal| author=Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM | display-authors=etal| title=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. | journal=J Am Coll Cardiol | year= 2022 | volume= 79 | issue= 2 | pages= e21-e129 | pmid=34895950 | doi=10.1016/j.jacc.2021.09.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34895950  }} </ref><ref name="pmid14724302">{{cite journal| author=Kastrati A, Mehilli J, Schühlen H, Dirschinger J, Dotzer F, ten Berg JM | display-authors=etal| title=A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. | journal=N Engl J Med | year= 2004 | volume= 350 | issue= 3 | pages= 232-8 | pmid=14724302 | doi=10.1056/NEJMoa031859 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14724302  }} </ref><ref name="pmid11368699">{{cite journal| author=O'Shea JC, Hafley GE, Greenberg S, Hasselblad V, Lorenz TJ, Kitt MM | display-authors=etal| title=Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: the ESPRIT trial: a randomized controlled trial. | journal=JAMA | year= 2001 | volume= 285 | issue= 19 | pages= 2468-73 | pmid=11368699 | doi=10.1001/jama.285.19.2468 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11368699  }} </ref><ref name="pmid11145489">{{cite journal| author=ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy| title=Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. | journal=Lancet | year= 2000 | volume= 356 | issue= 9247 | pages= 2037-44 | pmid=11145489 | doi=10.1016/S0140-6736(00)03400-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11145489  }} </ref>
 |-
-| bgcolor="lightpink"|[[Prasugrel]] should not be administered in [[patients]] with a history of [[stroke]] or [[transient ischemic attack]] who are undergoing [[PCI]].
+| bgcolor="lightpink"|1. [[Prasugrel]] should not be administered in [[patients]] with a history of [[stroke]] or [[transient ischemic attack]] who are undergoing [[PCI]].
+. The routine use of an [[intravenous]] [[glycoprotein IIb/IIIa inhibitor]] is not recommended in [[patients]] with stable [[ischemic heart disease]] undergoing [[PCI]].
 |}