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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e58

CLINICAL STATEMENTS AND GUIDELINES 1 B-R 2.	 In patients with ACS undergoing PCI, a loading dose of P2Y12 inhibitor, followed by daily dosing, is recommended to reduce ischemic events.5-15

1 C-LD 3.	 In patients with SIHD undergoing PCI, a loading dose of clopidogrel, followed by daily dosing, is recommended to reduce ischemic events.8,12,15-19

1 C-LD 4.	 In patients undergoing PCI within 24 hours after fibrinolytic therapy, a loading dose of 300 mg of clopidogrel, followed by daily dosing, is recommended to reduce ischemic events.5

2a B-R 5.	 In patients with ACS undergoing PCI, it is reasonable to use ticagrelor or prasugrel in preference to clopidogrel to reduce ischemic events, including stent thrombosis.6,14,20

2b B-R 6.	 In patients <75 years of age undergoing PCI within 24 hours after fibrinolytic therapy, ticagrelor may be a reasonable alternative to clopidogrel to reduce ischemic events.21

3: Harm B-R 7.	 In patients undergoing PCI who have a history of stroke or transient ischemic attack, prasugrel should not be administered.6

Synopsis DAPT with aspirin and oral P2Y12 inhibitors remains the cornerstone of therapy for the prevention of thrombotic complications with PCI. In the early days of PCI, aspirin was found to be effective at decreasing coronary throm- bosis with balloon angioplasty,1 and since that time, aspirin has remained a key agent for patients with chronic vascular disease.2-4 The contemporary oral P2Y12 inhibitors used in PCI include clopidogrel, ticagrelor, and prasugrel. Patients should be treated with a loading dose of these agents, either before PCI or otherwise at the time of PCI (Table 9). Clopidogrel is the least potent agent, requiring longer time to platelet inhibition after a loading dose. In patients with stable angina, there is no compelling evidence to support routine pretreatment with a P2Y12 inhibitor before coronary angiography when the coronary anatomy is not known.22 This is especially important because the need for CABG still occurs in a nonnegligible proportion of patients referred for angiography, and pretreatment can result in postponement of surgery.18 The duration of treatment with DAPT is discussed in Section 14.

Recommendation-Specific Supportive Text

1.	 Aspirin is protective in most types of patients with an increased risk of occlusive vascular events, including those with an AMI or ischemic stroke, unstable or stable angina, and previous MI.2,3 Aspirin reduces the frequency of ischemic complications after PCI and should be given in the periprocedural period.1,23 Although the minimum effective dose of aspirin in the setting of PCI has not been established, non–enteric-coated aspirin (325 mg) is commonly administered before PCI in those patients who were not previously on aspirin.1,24

Recommendations for Aspirin and Oral P2Y12 Inhibitors in Patients Undergoing PCI (Continued)

COR LOE Recommendations

Table 9.  Oral and Parenteral Antiplatelet Agents for Patients Undergoing PCI Drug Loading Dose Maintenance Dose Oral antiplatelet agents Aspirin Loading dose of 162-325 mg orally11

Aspirin may be chewed to achieve faster action Maintenance dose of 75-100 mg orally daily24,25

Clopidogrel Loading dose of 600 mg orally19

A lower loading dose of 300 mg should be considered in patients after fibrinolytic therapy5 Maintenance dose of 75 mg orally daily34

Prasugrel Loading dose of 60 mg orally20 Maintenance dose of 10 mg orally daily20

In patients with body weight <60 kg, a maintenance dose of 5 mg orally daily is recommended35 In patients ≥75 years of age, a dose of 5 mg orally daily can be used if deemed necessary35

Ticagrelor Loading dose of 180 mg orally14

Ticagrelor may be chewed to achieve faster action Maintenance dose of 90 mg orally twice a day14

Intravenous antiplatelet agents Abciximab (GPI)* Bolus of 0.25 mg/kg36 Maintenance of 0.125 μg/kg/min infusion (maximum 10 g/min) for 12 h.36 Eptifibatide (GPI) Double bolus of 180 μg/kg (given at a 10-min interval)37 Maintenance infusion of 2.0 μg/kg/min for up to 18 h37 Tirofiban (GPI) Bolus of 25 μg/kg over 3 min38 Maintenance infusion of 0.15 μg/kg/min for up to 18 h38 Cangrelor Bolus of 30 μg/kg39 Maintenance infusion 4 μg/kg/min for at least 2 h or duration of the procedure, whichever is longer39 GPI indicates glycoprotein IIb/IIIa inhibitor; and PCI, percutaneous coronary intervention. *Abciximab may not be readily available to clinicians in the United States.

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