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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e61 CLINICAL STATEMENTS AND GUIDELINES platelet aggregation,9 the use of glycoprotein IIb/ IIIa receptor inhibitors in the era of more potent antiplatelet agents is generally reserved for patients with a large thrombus burden or no-reflow or slow flow that is believed to be attributable to distal embolization of thrombus. 2. In patients with SIHD who are undergoing PCI, the use of glycoprotein IIb/IIIa receptor inhibitors in addition to a clopidogrel load does not reduce ischemic events.3,4 Patients enrolled in the ISAR-REACT (iNtracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) trial who were randomized to pretreatment with abciximab and a 600mg loading dose of clopidogrel had outcomes similar to those of patients receiving clopidogrel alone.3 Major bleeding was not significantly different between the 2 groups, although the rate of severe thrombocytopenia was significantly higher in the abciximab group.3 A subgroup analysis of the ESPRIT (Enhance Suppression of the Platelet IIB/IIIA receptor with Integrilin Therapy) trial showed no benefit in the primary endpoint of death, MI, urgent target-vessel revascularization, and thrombotic bailout with glycoprotein IIb/IIIa inhibitor therapy with eptifibatide at 48 hours in the group of patients undergoing PCI for stable angina.5 Six-month rates of death or MI were also not significantly different in this subgroup of patients.4 11.4 Heparin, Low-Molecular-Weight Heparin, and Bivalirudin in Patients Undergoing PCI Recommendations for Heparin, Low-Molecular-Weight Heparin, and Bivalirudin in Patients Undergoing PCI Referenced studies that support the recommendations are summarized in Online Data Supplement 35. COR LOE Recommendations 1 C-EO 1. In patients undergoing PCI, administration of intravenous unfractionated heparin (UFH) is useful to reduce ischemic events. 1 C-LD 2. In patients with heparin-induced thrombocytopenia undergoing PCI, bivalirudin or argatroban should be used to replace UFH to avoid thrombotic complications.1,2 2b A 3. In patients undergoing PCI, bivalirudin may be a reasonable alternative to UFH to reduce bleeding.3-12 2b B-R 4. In patients treated with upstream subcutaneous enoxaparin for unstable angina or NSTE- ACS, the use of intravenous enoxaparin may be considered at the time of PCI to reduce ischemic events.13-17 3: Harm B-R 5. In patients on therapeutic subcutaneous enoxaparin, in whom the last dose was administered within 12 hours of PCI, UFH should not be used for PCI and may increase bleeding.14,18,19 Synopsis Antithrombotic therapy is a mainstay of treatment in patients undergoing PCI. Currently, there are 3 antithrombotic agents that have been studied in PCI. These are UFH, bivalirudin, and enoxaparin. Fondaparinux is no longer recommended as the only anticoagulant in PCI because of a higher incidence of guiding-catheter thrombosis.20,21 Consideration of the patient’s clinical presentation (eg, stable disease, NSTE-ACS, or STEMI) and bleeding risk profile22 may influence selection of the optimal anticoagulant type. Suggested dosing regimens of parenteral agents are shown in Table 10. Recommendation-Specific Supportive Text 1. As the only anticoagulant available for many years, UFH has been the standard of care by default and the primary comparator for novel agents in RCTs.23 Dosing recommendations were established from early studies that demonstrated a relationship between activated clotting times and ischemic complications,23-26 but it is unclear that these analyses translate to the modern coronary stent era.27-31 Thus, the exact use of dosing based on activated clotting times in current practice is uncertain. The routine use of full-dose anticoagulation therapy after PCI is no longer indicated. 2. Heparin-induced thrombocytopenia occurs when the heparin molecule binds to platelet factor 4. Argatroban and bivalirudin are direct thrombin inhibitors and do not bind to platelet factor 4. Because of their different mechanism of action, argatroban1 and bivalirudin2 are acceptable alternative anticoagulants for use in patients with heparin-induced thrombocytopenia. 3. RCTs comparing bivalirudin and heparin have reported no difference in ischemic endpoints; however, less bleeding was reported with bivalirudin.3-7,9,29,32-37 Although the reduction in bleeding complications with the use of bivalirudin was seen in most trials, in real-world practice, this benefit may be less pronounced with routine use of radial artery intervention and low rates of glycoprotein IIb/IIIa inhibitor use. Meta-analyses of clinical trial data support these findings, highlighting that the magnitude of the lower bleeding risk with bivalirudin in various trials depended on variable inclusion of a glycoprotein IIb/IIIa inhibitor.10,11 The VALIDATE-SWEDEHEART (Bivalirudin vs Heparin in NSTEMI and STEMI in Patients on Modern Antiplatelet Therapy in SWEDEHEART) study38 examined a prolonged bivalirudin infusion versus UFH. Patients were treated with the more potent P2Y12 inhibitors, 90% had radial artery access, and there was a low rate of glycoprotein IIb/IIIa Downloaded from http://ahajournals.org by on October 7, 2026