Clinical judgment is required, and discussion with the interventional cardiologist is recommended. DAPT with aspirin and either clopidogrel or prasugrel has increased the risk of ICH in several clinical trials and patient populations (especially in those with prior stroke).260,296 298 In PLATO, the number of patients with prior stroke was small, limitingthepowertodetecttreatmentdifferencesinintracranial bleeding in this subgroup.299 Until further data become avail- able, it would seem prudent to weigh the possible increased risk of intracranial bleeding when the addition of ticagrelor to aspirin is considered in patients with prior stroke or transient Evidence to support the use of intravenous GP IIb/IIIa recep- tor antagonists in patients with STEMI was established largely before the use of oral DAPT. Although several studies have failed to show benefit with the administration of upstream GP IIb/IIIa receptor antagonists before primary PCI in the setting of DAPT with either UFH or bivalirudin anticoagula- a meta-analysis restricted to the use of abciximab has suggested it may be useful in this setting.277 The adjunctive use of GP IIb/IIIa agents at the time of PCI can be considered on an individual basis for large thrombus burden or inadequate receptor antagonist loading.265 270,301 For patients receiv- ing bivalirudin as the primary anticoagulant, routine adjunctive use of GP IIb/IIIa inhibitors is not recommended248 but may be considered as adjunctive or bail-out therapy in selected Studies of intracoronary GP IIb/IIIa administra- tion during primary PCI have shown mixed results for a variety of surrogate and combined clinical endpoints. Use of intracoro- nary abciximab may be reasonable in select cases.223,278 284 4.4.2. Anticoagulant Therapy to Support Primary PCI: Recommendations Class I 1. 