This chapter about antithrombotic
therapy during
percutaneous coronary intervention (PCI) is part of the seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading, see Guyatt et al, CHEST 2004;126:179S-187S). Among the key recommendations in this chapter are the following: For patients undergoing PCI, we recommend pretreatment with
aspirin, 75 to 325 mg (Grade 1A). For long-term treatment after PCI, we recommend
aspirin, 75 to 162 mg/d (Grade 1A). For long-term treatment after PCI in patients who receive
antithrombotic agents such as
clopidogrel or
warfarin, we recommend lower-dose
aspirin, 75 to 100 mg/d (Grade 1C+). For patients who undergo
stent placement, we recommend the combination of
aspirin and a
thienopyridine derivative (
ticlopidine or
clopidogrel) over systemic anticoagulation
therapy (Grade 1A). We recommend
clopidogrel over
ticlopidine (Grade 1A). For all patients undergoing PCI, particularly those undergoing primary PCI, or those with refractory
unstable angina or other high-risk features, we recommend use of a
glycoprotein (
GP) IIb-IIIa antagonist (
abciximab or
eptifibatide) [Grade 1A]. In patients undergoing PCI for ST-segment elevation MI, we recommend
abciximab over
eptifibatide (Grade 1B). In patients undergoing PCI, we recommend against the use of
tirofiban as an alternative to
abciximab (Grade 1A). In patients after uncomplicated PCI, we recommend against routine postprocedural infusion of
heparin (Grade 1A). For patients undergoing PCI who are not treated with a
GP IIb-IIIa antagonist, we recommend
bivalirudin over
heparin during PCI (Grade 1A). In PCI patients who are at low risk for complications, we recommend
bivalirudin as an alternative to
heparin as an adjunct to
GP IIb-IIIa antagonists (Grade 1B). In PCI patients who are at high risk for
bleeding, we recommend that
bivalirudin over
heparin as an adjunct to
GP IIb-IIIa antagonists (Grade 1B). In patients who undergo PCI with no other indication for systemic anticoagulation
therapy, we recommend against routine use of
vitamin K antagonists after PCI (Grade 1A).