Antithrombotic therapy after coronary stenting in patients receiving long-term anticoagulation
- Nikolaus Sarafoff, MD
Nikolaus Sarafoff, MD
- Klinikum der Ludwig Maximilians Universität
- Munich, Germany
- David R Holmes, Jr, MD
David R Holmes, Jr, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
Some patients with cardiovascular disease have indications for anticoagulant and antiplatelet therapy. It is estimated that between 5 and 10 percent of patients scheduled for coronary artery stenting and who require dual antiplatelet therapy (DAPT) are receiving oral anticoagulation (OAC), most often for atrial fibrillation (AF) [1,2] (see "Long-term antiplatelet therapy after coronary artery stenting in stable patients"). The concomitant use of DAPT using aspirin and a platelet P2Y12 receptor blocker and OAC is referred to as triple oral antithrombotic therapy or triple therapy for short. While the use of three antithrombotic agents reduces the rate of ischemic events, the risk of bleeding is significantly increased compared with one or two antithrombotic agents. This topic will provide the clinician with a guide for choosing the antithrombotic regimen for patients with an indication for anticoagulant and antiplatelet therapy after percutaneous coronary intervention (PCI).
The periprocedural management of antithrombotic therapy is discussed elsewhere. (See "Periprocedural management of antithrombotic therapy in patients receiving long-term oral anticoagulation undergoing percutaneous coronary intervention", section on 'Elective patients' and "Periprocedural bleeding in patients undergoing percutaneous coronary intervention", section on 'Risk factors' and "Periprocedural and long-term gastrointestinal bleeding in patients undergoing percutaneous coronary intervention" and "Periprocedural complications of percutaneous coronary intervention", section on 'Vascular complications' and "Antithrombotic therapy for prosthetic heart valves: Management of bleeding and invasive procedures", section on 'Cardiac catheterization'.)
ASSESSING PATIENT ISCHEMIC AND BLEEDING RISK
For patients who are candidates for triple oral antithrombotic therapy (triple therapy) (see 'Introduction' above), the first step in choosing antithrombotic therapy is to assess ischemic and bleeding risks. In most patients, the risk factors for each overlap significantly, making assessment of net benefit (or risk) difficult.
●Ischemic risk – The risk of an ischemic event (myocardial infarction [MI], stroke, need for repeat revascularization, or cardiovascular death) is increased in patients with recent acute coronary syndrome (ACS) or stroke, complicated coronary artery disease or a suboptimal result at the time of percutaneous coronary intervention (PCI), the need to prematurely stop antithrombotic therapy, age ≥65 years, and chronic kidney disease. (See "Risk stratification after acute ST-elevation myocardial infarction", section on 'Early risk stratification'.)
●Bleeding risk – Risk factors include age ≥65 years, prior history of bleeding, and hypertension. Risk prediction models are available (table 1). (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity", section on 'Risk factors' and "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'Risk factors'.)
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- ASSESSING PATIENT ISCHEMIC AND BLEEDING RISK
- OUR APPROACH
- Patients on long-term OAC
- Patients on DAPT after stent placement
- Nonstented ACS patients requiring OAC
- NEWER ANTITHROMBOTIC AGENTS
- Alternatives to clopidogrel
- Alternatives to warfarin
- CHOICE OF STENT
- MANAGEMENT AFTER TRIPLE THERAPY
- MAJOR SOCIETY GUIDELINES
- SUMMARY AND RECOMMENDATIONS