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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 e60 CLINICAL STATEMENTS AND GUIDELINES to examine the safety of ticagrelor in patients treated with fibrinolytic therapy for STEMI.21 In this study, ticagrelor was found to be noninferior to clopidogrel in rates of TIMI major bleeding, fatal bleeding, and intracranial bleeding.21 7. A more detailed analysis of the TRITON study that was designed to evaluate net clinical benefit (MACE events plus bleeding) with prasugrel demonstrated no net benefit of prasugrel compared with clopidogrel for patients with low body weight (<60 kg) or those ≥75 years of age and found net harm with prasugrel for patients with previous transient ischemic attack or cerebrovascular accident.6 For this reason, prasugrel is contraindicated in patients with a history of transient ischemic attack or stroke. Caution is advised in the use of prasugrel in patients weighing <60 kg or in patients ≥75 years of age. 11.2 Intravenous P2Y12 Inhibitors in Patients Undergoing PCI Recommendation for Intravenous P2Y12 Inhibitors in Patients Undergoing PCI Referenced studies that support the recommendation are summarized in Online Data Supplement 33. COR LOE Recommendation 2b B-R 1. In patients undergoing PCI who are P2Y12 inhibitor naïve, intravenous cangrelor may be reasonable to reduce periprocedural ischemic events.1-3 Synopsis Cangrelor is a potent, direct, reversible, short-acting intravenous P2Y12 inhibitor with rapid onset of platelet inhibition and restoration of platelet function within 1 hour of discontinuation. Cangrelor thus provides rapid, predictable, and profound inhibition of platelets. It can be efficacious in preventing stent thrombosis and may be considered in patients who have not been pretreated with a P2Y12 inhibitor, in patients whose absorption of oral medications may be inhibited, or in patients who are unable to take oral medications. Cangrelor has been investigated within the CHAMPION (Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) program and compared with a loading dose of clopidogrel given at the time of PCI in 3 largescale clinical trials.1,2,4 There are no studies comparing cangrelor with a loading dose of ticagrelor or prasugrel given at the time of PCI. Recommendation-Specific Supporting Text 1. The CHAMPION PLATFORM and the CHAMPION PCI trials did not show a reduction in the primary outcome (ie, death, MI, or ischemia-driven revascularization at 48 hours) with cangrelor. However, in CHAMPION PLATFORM, cangrelor resulted in lower rates of the prespecified secondary outcomes of stent thrombosis and death.1 In the CHAMPION PHOENIX trial, the primary endpoint, which included death, MI, ischemia-driven revascularization, or stent thrombosis, was significantly reduced with cangrelor.2 This was driven mainly by a reduction in periprocedural MI and intraprocedural stent thrombosis. A pooled patient-level meta-analysis of the CHAMPION trials supported these findings, demonstrating a lower rate of the composite endpoint of death, MI, ischemia-driven revascularization, or stent thrombosis at 48 hours with cangrelor than with clopidogrel.3 Additionally, cangrelor was associated with a 41% reduction in stent thrombosis. Although major bleeding was similar between the groups, minor bleeding was more frequent in the cangrelor group.3 11.3 Intravenous Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing PCI Recommendations for Intravenous Glycoprotein IIb/IIIa Inhibitors in Patients Undergoing PCI Referenced studies that support the recommendations are summarized in Online Data Supplement 34. COR LOE Recommendations 2a C-LD 1. In patients with ACS undergoing PCI with large thrombus burden, no-reflow, or slow flow, intravenous glycoprotein IIb/IIIa inhibitor agents are reasonable to improve procedural success.1,2 3: No Benefit B-R 2. In patients with SIHD undergoing PCI, the routine use of an intravenous glycoprotein IIb/ IIIa inhibitor agent is not recommended.3-5 Synopsis Glycoprotein IIb/IIIa receptor inhibitors are direct-acting antiplatelet agents targeting the glycoprotein IIb/IIIa platelet receptor. Many of the trials of glycoprotein IIb/IIIa inhibitors in the setting of ACS were conducted in an era before the use of potent P2Y12 inhibitors or before routine stenting.2,6 Additionally, in the earlier trials, the time from presentation to coronary angiography was often prolonged. In the contemporary era of shorter revascularization times and use of potent DAPT, the benefit of glycoprotein IIb/IIIa receptor inhibitor agents is diminished.2,7 Recommendation-Specific Supporting Text 1. In trials of patients with ACS, glycoprotein IIb/ IIIa receptor inhibitors have not been associated with improved clinical outcomes and may increase bleeding complications.7,8 Because the addition of glycoprotein IIb/IIIa receptor inhibitors can decrease thrombus burden by further inhibiting Downloaded from http://ahajournals.org by on October 7, 2026