Preparation of the patient for PCI

There are several steps involved in preparing patients for PCI, which include shared decision-making and informed consent, preprocedural documentation and history and physical examination, preprocedural laboratory testing, preprocedural fasting and sedation, antiplatelet and anticoagulant premedication, vascular access site selection, management of patients on oral anticoagulants, prevention of contrast-induced acute kidney injury, management of allergies and potential anaphylactoid reactions, preprocedural timeout and safety checklists, use of statins, assessment of bleeding risk, evaluation of on-site surgical backup services, and consideration of same-day discharge eligibility. A Heart Team approach is recommended for complex revascularization decisions.

• Revascularization decisions should be patient centered — considerate of the patient’s preferences and goals, cultural beliefs, health literacy, and social determinants of health — and made in collaboration with the patient’s support system (Class 1, LOE C-LD).^[1] Adequate information about benefits, risks, therapeutic consequences, and potential alternatives should be given, when feasible, with sufficient time for informed decision-making (Class 1, LOE C-LD).^[1]

• Consent procedures should include:^[1][2]
• Plain language and teach-back documentation
• Trained interpreter when needed
• Patient-specific short- and long-term risks
• Information on operator expertise and facility volume
• The need for continued medical therapy and lifestyle modifications
• The potential for emergency surgery
• Preprocedural Documentation, History and Physical Examination

• All patients must have a history and physical (H&P) examination prior to the procedure, performed by either a physician or an advanced practice professional (APP).^[3] For outpatient procedures, a timed and dated H&P within 30 days is acceptable, with a focused update by the attending physician within 24 hours prior to the procedure. For inpatients, an H&P should be performed within 24 hours of admission.^[3]
• At a minimum, the H&P should include:^[3][4]
• History of present illness, CCS angina and NYHA heart failure classes
• Relevant medications (including those received within the last 48 hours)
• Relevant comorbidities
• Review of systems (renal, gastrointestinal, peripheral vascular, neurological, pulmonary)
• History of contrast reaction or other allergies
• Potential issues related to antiplatelet or anticoagulant therapy
• Barriers to long-term DAPT adherence
• Prior airway or sedation issues
• Physical examination should focus on the cardiopulmonary and vascular system and document peripheral pulses.^[3] Procedural indications should be well documented and reconciled with published appropriate use criteria (AUC).^[3] Risk scores and calculators (e.g., SCAI PCI Risk App) for predicting complications (mortality, bleeding, contrast-induced nephropathy) should be documented.^[3]
• For patients who have had prior catheterization or coronary/peripheral bypass surgery, every effort should be made to review procedural reports and prior cardiovascular angiograms.^[4]

Sources: SCAI 2021 Expert Consensus Update^[3]; SCAI 2016 Best Practices^[4]; 2012 ACCF/SCAI Expert Consensus Document^[2]

The ASA 2017 guidelines recommend clear liquids up to 2 hours prior and light meals up to 6 hours prior (8 hours for heavier meals).^[3] NPO instructions are typically waived for emergency procedures.^[3] Moderate sedation/analgesia is frequently sufficient for coronary artery procedures; anxiolysis or pain control alone may suffice. Physicians in the cardiac catheterization laboratory should be credentialed for providing moderate sedation.^[3]

Emerging evidence on nonfasting: The SCOFF trial (multicenter RCT, n=716) randomized patients to fasting vs. no fasting before cardiac catheterization procedures with conscious sedation. The primary composite outcome (aspiration pneumonia, hypotension, hyperglycemia, hypoglycemia) occurred in 19.1% of fasting vs. 12.0% of no-fasting patients, confirming non-inferiority (posterior probability >99.5%) and superiority (posterior probability 99.1%) of no fasting. Patient satisfaction scores were significantly better with no fasting (posterior mean difference 4.02 points).^[5] The TONIC trial similarly supported the safety of nonfasting before interventional coronary procedures under local anesthesia with moderate sedation.^[6] These findings are not yet incorporated into formal guidelines but represent a potential practice change.

Aspirin should be initiated with a loading dose (162-325 mg, nonenteric coated, chewed) in patients with ACS as soon as possible on presentation.^[7] Ticagrelor or prasugrel is recommended in preference to clopidogrel in patients with ACS undergoing PCI.^[7] DAPT with aspirin and an oral P2Y12 inhibitor is indicated for at least 12 months as the default strategy in patients with ACS who are not at high bleeding risk.^[7]

Source: 2025 ACC/AHA/ACEP/NAEMSP/SCAI ACS Guideline^[7]

When PCI is planned or anticipated, loading with aspirin 324 mg po (chewed) should be performed before the procedure if the patient is not already on daily aspirin.^[3] Loading before the procedure with a P2Y12 inhibitor is reasonable, although there is no evidence that pre-loading decreases ischemic complications compared to loading at the time of PCI or at its conclusion. Delaying P2Y12 loading until anatomy is known may prevent delays if anatomy demonstrates a need for CABG.^[3]

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Cangrelor is a potent, direct, reversible, short-acting IV P2Y12 inhibitor with rapid onset and restoration of platelet function within 1 hour of discontinuation. No studies have compared cangrelor with a loading dose of ticagrelor or prasugrel given at the time of PCI.^[1]

Glycoprotein IIb/IIIa inhibitors (GPIs) are generally only recommended for selected cases at high, life-threatening risk for ischemic complications or for bail-out situations.^[8] A pooled patient-level analysis from 3 phase 3 CHAMPION trials demonstrated that cangrelor‘s reduction in periprocedural ischemic complications was maintained irrespective of GPI use, while GPI use was associated with substantially higher bleeding rates regardless of randomization to cangrelor or clopidogrel.^[9]

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^[1] Fondaparinux is no longer recommended as the only anticoagulant in PCI because of a higher incidence of guiding-catheter thrombosis.^[1]

Target ACTs shown for HemoTec or I-Stat devices. For Hemochron ACT devices, ACT goals are 50 s higher. In CTO or ACS, consider higher target ACT. If IV GPI planned, target ACT 200-250 s. Source: 2021 ACC/AHA/SCAI Guideline^[1]

• The 2021 ACC/AHA/SCAI Guideline and the 2025 ACC/AHA ACS Guideline both recommend a radial approach (Class 1, LOE A) for patients undergoing PCI to reduce bleeding, vascular complications, and death.^[1][7] Transfemoral access, preferably with ultrasound-guidance, should be considered when temporary mechanical circulatory support is planned.^[7] In centers where expertise in the transradial approach is unavailable, or in patients unable to get radial artery catheterization, femoral artery access remains the default strategy.^[1] The decision to use the transradial approach should be tempered with the possibility that the radial artery may be needed for bypass grafting in the future.^[1] Alternative upper extremity sites (ulnar artery, distal radial artery) have yielded similar outcomes.^[7]
• The SCAI Expert Consensus Update (2021) recommends that all operators develop and maintain competency in both radial and femoral arterial vascular access, and that vascular ultrasound should be available for universal use.^[3]

• The 2020 ACC Expert Consensus Decision Pathway provides the following guidance for patients on oral anticoagulants undergoing PCI:^[10][8]
• All patients should receive aspirin 162-325 mg, preferably prior to the catheterization procedure
• A loading dose of P2Y12 inhibitor (clopidogrel 600 mg is the recommended agent) should be administered in the periprocedural period
• For patients on a VKA presenting with ACS without ST elevation who do not need coronary angiography urgently, bridging with UFH or LMWH may be necessary as the INR tapers off
• For those on a DOAC, there is likely no value in bridging, particularly with LMWH
• Patients on a DOAC undergoing elective procedures should withhold therapy for 24 hours (or 48 hours for patients with impaired renal function on dabigatran)
• Additional UFH should be administered during PCI at standard dose (70-100 U/kg) in case of DOACs and reduced dose (30-50 U/kg) in case of ongoing VKA
• Procedures should be carried out with radial access as part of a general periprocedural bleeding avoidance strategy
• Urgent or emergent procedures can be performed without withholding OAC
• Post-PCI: low-dose aspirin is recommended for the duration of hospitalization; in general, discontinue aspirin prior to/upon discharge in most patients, continuing OAC + P2Y12 inhibitor (clopidogrel preferred)

The SCAI Quality Initiatives for Prevention of CI-AKI (2025) recommend the following approach:^[11]

Use risk calculators (e.g., Mehran score) to predict risk of CI-AKI

• Pre- and post-procedural hydration: 1-1.5 mL/kg/hour NaCl × 3-12 hours pre-procedure; 12-24 hours post-procedure
• LVEDP-guided hydration (POSEIDON trial, n=396): 3 mL/kg 0.9% NaCl × 1 hour pre-procedure, then 5 mL/kg/h (LVEDP <13 mmHg), 3 mL/kg/h (LVEDP 13-18 mmHg), 1.5 mL/kg/h (LVEDP >18 mmHg) × 4 hours post-procedure — lowered CI-AKI by 60%

• Risk of CI-AKI increases by 12% for every 100 mL of contrast administered
• CV/CCC ratio should be kept <3 and ideally <2
• MACD equation: 5 × body weight (kg) / serum creatinine. Contrast Ratio (contrast volume/MACD) exceeding 1 is associated with progressive increase in CI-AKI risk

• Consider transradial access: TRA lowered CI-AKI by 23% compared with TFA in the AKI-MATRIX trial; dialysis risk lowered by 55% in the group without access site crossover^[12]
• Correct modifiable risk factors: periprocedural hypovolemia, hypotension, hyperglycemia, anemia; hold nephrotoxic drugs (ACE inhibitors, NSAIDs, ARBs)^[11]
• High-dose statins may reduce the occurrence of contrast-induced AKI^[13]
• When PCI is clinically needed, the risk of CI-AKI should not be a reason to withhold it in most patients with CKD^[13]

Allergies to latex, contrast, heparin (and history of HIT), aspirin, narcotics, antiplatelet agents, and other medications should be reviewed and documented.^[3]

Contrast Allergies:

• Oral prednisone 50 mg at 13, 7, and 1 hour prior to procedure. In addition to steroids, diphenhydramine and H2 blockers can be considered^[3]
• For emergent catheterization in patients with prior contrast reactions, emergency medication preparation followed by immediate catheterization appears to be associated with a very low risk of breakthrough contrast reactions^[3]
• Shellfish allergy is not a predictor of contrast reactions and does not require pretreatment^[3]

Aspirin Allergy:

If aspirin allergy is present, an aspirin desensitization protocol should be considered prior to stent placement when possible^[3]

• Diabetic patients usually have the insulin dose reduced by half the night prior and then held the morning of the procedure. Procedures should be scheduled early to avoid hypoglycemia^[2]
• Metformin should be held regardless of creatinine clearance and not restarted until postprocedural documentation that creatinine has returned to baseline^[2]

• A dedicated “time out” protocol should be performed before vascular access or moderate sedation is initiated, when all members of the team are present.^[3] Items reviewed during time-out include:
• Patient identity, procedure to be performed, planned primary and backup access site
• Equipment availability
• Patient allergies and pre-medication
• Special laboratory or medical conditions (INR, CKD)
• Appropriate documentation (H&P updated within 24 hours)
• Signed informed consent
• For ad-hoc coronary interventions, a “Pre-PCI time out” should be considered, including: appropriate use classification, radiation exposure and contrast dose, appropriateness of intravascular imaging or physiologic assessment, DAPT issues, adequate pre-treatment with aspirin and P2Y12 inhibitors, and baseline hemodynamics.^[3]
• Additional safety measures:^[3]
• All solutions on the table must be labeled in real-time (not prelabeled)
• Defibrillation pads should be placed on all STEMI patients and those at increased risk of cardiac arrest
• At least one working IV must be in place prior to the start of the procedure

• The 2021 ACC Expert Consensus Decision Pathway on Same-Day Discharge After PCI provides the following guidance:^[14]
• Practice patterns regarding P2Y12 inhibitor loading and maintenance vary among physicians, with providers initiating P2Y12 inhibitors either days before the procedure, in the pre-procedural area, or in the catheterization laboratory after defining coronary anatomy
• Orders for outpatient loading and maintenance or preprocedural DAPT loading should be confirmed in the EHR and communicated between preprocedural and procedural nursing
• In addition to the DAPT loading dose, the EHR should confirm prescriptions for aspirin and statin therapy as well as a referral to cardiac rehabilitation
• Special Populations — Older Adults

Comprehensive risk assessment in older adults should include: traditional cardiovascular risk assessment, minimum geriatric risk assessment (functional status and goals of care), and identification of high-risk clinical groups. Additional geriatric measures organized into four domains should be considered: medical conditions, cognitive and emotional health, physical function, and social environment.^[15]

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Routine rheolytic thrombectomy did not show any benefit based on trials done on patients with ST elevation myocardial infarction undergoing primary PCI even in the presence of thrombotic occlusion.^{[63][64][65][66][67][68]}

The following algorithm summarizes the key steps in preparing a patient for PCI:^[3][1][2]