Dosing of parenteral antithrombotic drugs for elective percutaneous coronary intervention (PCI)

Drug	Dose	Initiation relative to PCI	Duration of therapy
GP IIb/IIIa inhibitors^*
Eptifibatide	180 mcg/kg IV bolus x2, given 10 minutes apart (maximum 22.6 mg each bolus). Start maintenance infusion of 2 mcg/kg/minute (maximum 15 mg/hour) immediately after first bolus.	Immediately prior to PCI	Up to 18 to 24 hours after PCI
	Adjustment for kidney impairment: CrCl^¶ <50 mL/minute: Boluses as above. Maintenance infusion of 1 mcg/kg/minute (maximum 7.5 mg/hour). Hemodialysis dependent: contraindicated.
Tirofiban	25 mcg/kg IV bolus administered over ≤5 minutes beginning after diagnostic coronary angiography, just before PCI; maintenance infusion: 0.15 mcg/kg/minute continued for up to 18 hours.		Up to 18 hours after PCI
	Adjustment for kidney impairment (CrCl^¶ ≤60 mL/minute): IV Loading dose: 25 mcg/kg administered over ≤5 minutes; maintenance infusion: 0.075 mcg/kg/minute.
Anticoagulants
Unfractionated heparin (no prior anticoagulant therapy)^Δ	Without GP IIb/IIIa inhibitor: 70 to 100 units/kg IV bolus (maximum 10,000 units), with additional boluses if needed to achieve ACT target of 250 to 300 seconds^◊. With GP IIb/IIIa inhibitor: 50 to 70 units/kg IV bolus (maximum 7000 units), with additional boluses if needed to achieve ACT target of 200 to 250 seconds.	Immediately prior to PCI	Discontinued at the end of the procedure
	Adjustment for kidney impairment: None.
Enoxaparin	Not generally started for elective PCI. For the occasional patient already on 2 or more doses of therapeutic enoxaparin, it can be continued at prior dose with an additional 0.3 mg/kg IV if 8 to 12 hours since last SubQ dose. Refer to drug monograph for additional detail. If PCI >12 hours after last SubQ dose of therapeutic enoxaparin, an established anticoagulation regimen (eg, unfractionated heparin or bivalirudin) should be used		May continue for prior indication
	Adjustment for kidney impairment (CrCl^¶ <30 mL/minute or dialysis dependent): Avoid use.
Bivalirudin	0.75 mg/kg IV bolus, then maintenance infusion of 1.75 mg/kg/hour.	Immediately prior to PCI	Discontinued at the end of the procedure or continued for up to 4 hours after PCI
	Adjustment for kidney impairment: CrCl^¶ 10 to 29 mL/minute: IV bolus as above; maintenance infusion of 1 mg/kg/hour. Hemodialysis dependent: IV bolus as above; maintenance infusion of 0.25 mg/kg/hour.

PCI: percutaneous coronary intervention; GP: glycoprotein; IV: intravenous; CrCl: creatinine clearance; ACT: activated clotting time.

* Refer to clinical topic for approach to agent selection and timing of antithrombotic therapy with aspirin, platelet P2Y12 receptor blockers, parenteral anticoagulants, and GP IIb/IIIa inhibitors. UpToDate limits use of a GP IIb/IIIa inhibitor to selected higher thrombotic risk patients; refer to clinical topic.

¶ CrCl is estimated using Cockcroft-Gault equation. A calculator for determination of CrCl by Cockcroft Gault equation is available in UpToDate.

Δ If the patient received previous anticoagulation with heparin, IV bolus(es) (eg, 2000 to 5000 units) are given as needed to achieve target ACT.

◊ Goal ACT may vary depending on point-of-care ACT device.

Adapted from:

Antiplatelet and anticoagulant drugs. The Medical Letter 2008; 6:29.
Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 79:e21.

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Dosing of parenteral antithrombotic drugs for elective percutaneous coronary intervention (PCI)