Oral Antiplatelet Agents in Percutaneous Coronary Intervention

Oral antiplatelet therapy (APT) is a critical adjunct to percutaneous coronary intervention (PCI) in order to reduce post-procedural ischemic complications, such as stent thrombosis. At present, dual antiplatelet therapy (DAPT) – comprising aspirin and a P2Y₁₂-receptor antagonist – remains the mainstay of evidence-based antiplatelet therapy. In all indications for PCI, a 150–300 mg loading dose of aspirin, followed by 75–100 mg life-long daily maintenance dose, is recommended. In PCI for chronic coronary syndrome (CCS), a 600 mg clopidogrel loading dose, followed by 75 mg daily, should be administered. In PCI for NSTEACS, DAPT is recommended with a potent P2Y₁₂-receptor antagonist; either prasugrel (60 mg loading and 10 mg daily maintenance dose), ticagrelor (180 mg loading and 90 mg twice-daily maintenance dose). It is no longer recommended to administer routine pre-treatment with a P2Y12 receptor inhibitor to NSTEACS patients in whom the coronary anatomy is not known and early invasive management is planned. DAPT-treated patients experience adverse sequelae, such as recurrent ischaemic events, and bleeding-associated complications. Strategies optimizing the application of existing antiplatelet agents, such as the individualization of dosing regimens, based on pharmacogenetic indices and platelet reactivity testing, remain an active area of research. This chapter reviews the efficacy and safety of oral antiplatelet regimens, summarizes up-to-date, evidence-based clinical guidelines, and addresses the questions that remain unanswered with regard to the optimization of oral antiplatelet pharmacotherapy.