Pharmacology before, during and after percutaneous coronary intervention

### Learning objectives Coronary intervention initiates thrombin generation through endothelial damage and plaque disruption. The subsequent thrombotic risk1 can persist for several weeks and dissipates, but not disappear, after stent endothelialisation. Adjunctive antithrombotic pharmacology, therefore, is a key determinant of acute and long-term outcomes with the range of available options improving outcomes but adding complexity to the decision making process. This review will focus on antithrombotic pharmacology before, during and after percutaneous coronary intervention (PCI) with stent deployment. The major trials of antithrombotic drugs are listed in table 1 and those of extended and shortened duration in tables 2 and 3, respectively. View this table: Table 1 Summary of pivotal trials for antithrombotic agents View this table: Table 2 Trials of prolonged duration of antithrombotics View this table: Table 3 Trials of short duration DAPT Pretreatment refers to pharmacology given (in ambulance or Emergency Department) before coronary anatomy is defined. Given the pathophysiology of coronary revascularisation, pretreatment with P2Y12 inhibitors would be expected to reduce ischaemic events. However, this benefit has to be balanced with increased bleeding risk in patients who have non-obstructive disease or those referred for surgical revascularisation. The evidence base for patient benefit of pretreatment with oral P2Y12 inhibitors is limited but all patients should be given a loading dose of aspirin. ### Stable angina The evidence for pretreatment arose from the CREDO trial2 which demonstrated benefit if patients received clopidogrel 300 mg loading at least 6 hours before PCI . However, closer analysis of patient inclusion revealed that most were selected after coronary angiography. The only trial designed to test pretreatment was PRAGUE-8 which failed to show ischaemic benefit between prehospital 600 mg clopidogrel compared with in-laboratory …