Role of intravenous P2Y₁₂ inhibition in high-risk percutaneous coronary intervention

Technological advancements have improved safety and efficacy outcomes in patients undergoing complex and high-risk percutaneous coronary intervention (PCI). Increasingly, patients present to the cardiac catheterization laboratory both acutely and electively with advanced age, multiple comorbidities, and complex anatomy, representing a higher-risk group of patients who also may have the most to gain from percutaneous revascularization, as their response to medical therapy is usually limited and surgical risks may be prohibitive. These patients typically face thrombosis, slow flow, and other adverse events during and after PCI, which carry significant risk, especially given patients' poor surgical candidacy. Accordingly, optimal antiplatelet and anticoagulant therapies are pivotal to limiting periprocedural thrombotic risk. Oral P2Y₁₂ inhibitors have proven effective in reducing short-term and long-term cardiovascular events, although reduced bioavailability and delayed onset of action limit their efficacy during the procedural and immediate aftermath phases of PCI. Although intravenous glycoprotein IIb/IIIa receptor inhibitors are effective in reducing thrombotic events, bleeding risks have attenuated their use, and recent guidelines relegate their use to bailout. Best practices concerning intraprocedural antiplatelet therapies in patients undergoing complex PCI therefore remain unclear. The inherently high risks of thrombosis and bleeding among these patients must be balanced and considered when determining an antiplatelet strategy. Given the potential advantages of achieving potent but rapidly reversible P2Y₁₂ inhibition in high-risk PCI, we review the data surrounding intravenous P2Y₁₂ inhibition in this setting and provide best practice recommendations for clinical use.