Post PCI management

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Stable Angina

Unstable Angina

Non ST Elevation MI

ST Elevation MI

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention: Post-procedural Antiplatelet Therapy [1] (DO NOT EDIT)

Class I
"1. After PCI, use of aspirin should be continued indefinitely.[2][3][4][5] (Level of Evidence: A)"
"2. The duration of P2Y12 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 inhibitor therapy should be given for at least 12 months. Options include clopidogrel 75 mg daily [6], prasugrel 10 mg daily [7], and ticagrelor 90 mg twice daily.[8] (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 the patient is not at high risk of bleeding.[9][10][11] (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).[12] (Level of Evidence: B)"
"3. Patients should be counseled on the importance of compliance with dual antiplatelet therapy (DAPT) and that therapy should not be discontinued before discussion with their cardiologist.[11] (Level of Evidence: C)"
Class III (No Benefit)
"1. Continuation of clopidogrel, prasugrel or ticagrelor beyond 12 months may be considered in patients undergoing placement of drug eluting stent (DES).[7][8] (Level of Evidence: C)"
Class IIa
"1. After PCI, it is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses.[13][14][15][16][17] (Level of Evidence: B)"
"2. If the risk of morbidity from bleeding outweighs the anticipated benefit afforded by a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., less than 12 months) of P2Y12 inhibitor therapy is reasonable. (Level of Evidence: C)"

ACCF/AHA/SCAI 2011 Guidelines for Percutaneous Coronary Intervention: Post-Procedural Proton Pump Inhibitors and Anti-platelet Therapy[1] (DO NOT EDIT)

Class I
"1. Proton pump inhibitors should be used in patients with a history of prior gastrointestinal bleeding who require dual antiplatelet therapy (DAPT).[18] (Level of Evidence: C)"
Class III (No Benefit)
"1. Routine use of a proton pump inhibitor is not recommended for patients at low risk of gastrointestinal bleeding, who have much less potential to benefit from prophylactic therapy.[18] (Level of Evidence: C)"
Class IIa
"1. Use of proton pump inhibitors is reasonable in patients with an increased risk of gastrointestinal bleeding (e.g., advanced age, concomitant use of warfarin, steroids, nonsteroidal antiinflammatory drugs, Helicobacter pylori infection) who require dual antiplatelet therapy (DAPT).[18] (Level of Evidence: C)"

ACCF/AHA/SCAI 2011 Guidelines for Percutaneous Coronary Intervention: Post-Procedural Clopidogrel Genetic Testing[1] (DO NOT EDIT)

Class III (No Benefit)
"1. The routine clinical use of genetic testing to screen patients treated with clopidogrel who are undergoing PCI is not recommended.[19] (Level of Evidence: C)"
Class IIb
"1. Genetic testing might be considered to identify whether a patient at high risk for poor clinical outcomes is predisposed to inadequate platelet inhibition with clopidogrel.[19] (Level of Evidence: C)"
"2. When a patient predisposed to inadequate platelet inhibition with clopidogrel is identified by genetic testing, treatment with an alternate P2Y12 inhibitor (e.g., prasugrel or ticagrelor) might be considered.[19] (Level of Evidence: C)"

ACCF/AHA/SCAI 2011 Guidelines for Percutaneous Coronary Intervention: Post-Procedural Platelet Function Testing[1] (DO NOT EDIT)

Class III (No Benefit)
"1. The routine clinical use of platelet function testing to screen patients treated with clopidogrel who are undergoing PCI is not recommended.[19] (Level of Evidence: C)"
Class IIb
"1. Platelet function testing may be considered in patients at high risk for poor clinical outcomes.[19] (Level of Evidence: C)"
"2. In patients treated with clopidogrel with high platelet reactivity, alternative agents, such as prasugrel or ticagrelor, might be considered.[19] (Level of Evidence: C)"

References

  1. 1.0 1.1 1.2 1.3 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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  3. "Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients". BMJ (Clinical Research Ed.). 324 (7329): 71–86. 2002. PMC 64503. PMID 11786451. Retrieved 2011-12-16. Unknown parameter |month= ignored (help)
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  7. 7.0 7.1 Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, Neumann FJ, Ardissino D, De Servi S, Murphy SA, Riesmeyer J, Weerakkody G, Gibson CM, Antman EM (2007). "Prasugrel versus clopidogrel in patients with acute coronary syndromes". The New England Journal of Medicine. 357 (20): 2001–15. doi:10.1056/NEJMoa0706482. PMID 17982182. Retrieved 2011-12-16. Unknown parameter |month= ignored (help)
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  9. 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 2011-12-16. Unknown parameter |month= ignored (help)
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  12. Steinhubl SR, Berger PB, Mann JT, Fry ET, DeLago A, Wilmer C, Topol EJ (2002). "Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial". JAMA : the Journal of the American Medical Association. 288 (19): 2411–20. PMID 12435254. Retrieved 2011-12-16. Unknown parameter |month= ignored (help)
  13. Jolly SS, Pogue J, Haladyn K, Peters RJ, Fox KA, Avezum A, Gersh BJ, Rupprecht HJ, Yusuf S, Mehta SR (2009). "Effects of aspirin dose on ischaemic events and bleeding after percutaneous coronary intervention: insights from the PCI-CURE study". European Heart Journal. 30 (8): 900–7. doi:10.1093/eurheartj/ehn417. PMID 18819961. Retrieved 2011-12-16. Unknown parameter |month= ignored (help)
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  15. Steinhubl SR, Bhatt DL, Brennan DM, Montalescot G, Hankey GJ, Eikelboom JW, Berger PB, Topol EJ (2009). "Aspirin to prevent cardiovascular disease: the association of aspirin dose and clopidogrel with thrombosis and bleeding". Annals of Internal Medicine. 150 (6): 379–86. PMID 19293071. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
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  17. Peters RJ, Mehta SR, Fox KA, Zhao F, Lewis BS, Kopecky SL, Diaz R, Commerford PJ, Valentin V, Yusuf S (2003). "Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study". Circulation. 108 (14): 1682–7. doi:10.1161/01.CIR.0000091201.39590.CB. PMID 14504182. Retrieved 2011-12-16. Unknown parameter |month= ignored (help)
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  19. 19.0 19.1 19.2 19.3 19.4 19.5 Holmes DR, Dehmer GJ, Kaul S, Leifer D, O'Gara PT, Stein CM (2010). "ACCF/AHA clopidogrel clinical alert: approaches to the FDA "boxed warning": a report of the American College of Cardiology Foundation Task Force on clinical expert consensus documents and the American Heart Association endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons". Journal of the American College of Cardiology. 56 (4): 321–41. doi:10.1016/j.jacc.2010.05.013. PMID 20633831. Retrieved 2011-12-16. Unknown parameter |month= ignored (help)

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