Dual antiplatelet therapy (DAPT) is essential before and after PCI. All patients should be loaded with aspirin and either clopidogrel, prasugrel or ticagrelor. Patients who are currently taking these medicines should be reloaded before PCI, in case adherence has been suboptimal.
Statins should ideally be started before PCI, due to their beneficial pleiotropic effects. Reduced thrombosis risk in the short term has been demonstrated when statins are used before PCI compared with commencing them after PCI.
DAPT is usually used for up to 12 months. Actual duration is often determined by the patient's bleeding and thrombotic risk and the type of coronary stent deployed. Drug eluting stents (DES) take longer to endothelialise (i.e., be incorporated into the artery wall) than a bare metal stent (BMS). Most guidelines suggest DAPT for 12 months for patients with a DES, and a minimum of 4-6 weeks for those with a BMS. However, those with a BMS and a low risk of bleeding often receive the full 12 months of DAPT. Patients who are managed medically without PCI usually remain on DAPT for 12 months. Older age and tobacco use increase the risk of bleeding.[#levine-gn-bates-er-blankenship-jc-et-al.-2011] Those who have previously had a thrombotic event after PCI may remain on DAPT for more than 12 months or indefinitely.
Avoid glycoprotein IIb/IIIa receptor antagonists where possible, except for high-risk NSTEMI. Some evidence supports tirofiban in patients with NSTEMI awaiting PCI and abciximab use in patients during PCI. However, the trials supporting this generally were conducted prior to dual antiplatelet use; PCI/stent technology has developed to such an extent that outcomes from earlier treatment trials may no longer be relevant.