Antithrombotic therapy for elective percutaneous coronary intervention: General use
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- Thomas Levin, MD
Thomas Levin, MD
- Illinois Heart and Vascular
- Chicago, Illinois
Percutaneous coronary intervention (PCI) disrupts the coronary endothelium, leading to the exposure of subendothelial tissue factors to blood. Intracoronary thrombosis may result during or soon after the procedure. In addition, metal (which is procoagulant) stents can trigger thrombus formation. Stent thrombosis can be a life-threatening event. (See "Coronary artery stent thrombosis: Clinical presentation and management" and "Coronary artery stent thrombosis: Incidence and risk factors".)
Aggressive antithrombotic therapy with aspirin, platelet P2Y12 receptor blockers, glycoprotein (GP) IIb/IIIa inhibitors, and parenteral anticoagulants is used to decrease the risk of early intracoronary thrombosis. Recommendations for the use of these agents in stable patients before and within the first few days of stent placement will be the focus of this topic. The studies supporting these recommendations are presented separately. (See "Antithrombotic therapy for elective percutaneous coronary intervention: Clinical studies".)
The discussion of the long-term use of aspirin and platelet P2Y12 receptor blockers to prevent late and very late stent thrombosis is found elsewhere. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients".)
The use of antithrombotic therapy in the setting of acute coronary syndromes (ACS) is discussed elsewhere. (See "Antiplatelet agents in acute ST elevation myocardial infarction" and "Antiplatelet agents in acute non-ST elevation acute coronary syndromes" and "Anticoagulant therapy in non-ST elevation acute coronary syndromes" and "Anticoagulant therapy in acute ST elevation myocardial infarction".)
We prescribe antithrombotic therapy to stable patients undergoing elective PCI with stenting in the following sequential manner:
- Schwartz L, Bourassa MG, Lespérance J, et al. Aspirin and dipyridamole in the prevention of restenosis after percutaneous transluminal coronary angioplasty. N Engl J Med 1988; 318:1714.
- Lembo NJ, Black AJ, Roubin GS, et al. Effect of pretreatment with aspirin versus aspirin plus dipyridamole on frequency and type of acute complications of percutaneous transluminal coronary angioplasty. Am J Cardiol 1990; 65:422.
- http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm452172.htm (Accessed on June 23, 2015).
- http://www.accessdata.fda.gov/drugsatfda_docs/appletter/2015/204958Orig1s000ltr.pdf (Accessed on June 23, 2015).
- Bellemain-Appaix A, O'Connor SA, Silvain J, et al. Association of clopidogrel pretreatment with mortality, cardiovascular events, and major bleeding among patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. JAMA 2012; 308:2507.
- Steinhubl SR, Berger PB, Mann JT 3rd, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002; 288:2411.
- Collet JP, Silvain J, Landivier A, et al. Dose effect of clopidogrel reloading in patients already on 75-mg maintenance dose: the Reload with Clopidogrel Before Coronary Angioplasty in Subjects Treated Long Term with Dual Antiplatelet Therapy (RELOAD) study. Circulation 2008; 118:1225.
- Di Sciascio G, Patti G, Pasceri V, et al. Clopidogrel reloading in patients undergoing percutaneous coronary intervention on chronic clopidogrel therapy: results of the ARMYDA-4 RELOAD (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty) randomized trial. Eur Heart J 2010; 31:1337.
- Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610.
- Bennett CL, Connors JM, Carwile JM, et al. Thrombotic thrombocytopenic purpura associated with clopidogrel. N Engl J Med 2000; 342:1773.
- Kastrati A, Mehilli J, Schühlen H, et al. A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. N Engl J Med 2004; 350:232.
- Kandzari DE, Berger PB, Kastrati A, et al. Influence of treatment duration with a 600-mg dose of clopidogrel before percutaneous coronary revascularization. J Am Coll Cardiol 2004; 44:2133.
- Puma JA, Banko LT, Pieper KS, et al. Clinical characteristics predict benefits from eptifibatide therapy during coronary stenting: insights from the Enhanced Suppression of the Platelet IIb/IIIa Receptor With Integrilin Therapy (ESPRIT) trial. J Am Coll Cardiol 2006; 47:715.
- PRICE Investigators. Comparative 30-day economic and clinical outcomes of platelet glycoprotein IIb/IIIa inhibitor use during elective percutaneous coronary intervention: Prairie ReoPro versus Integrilin Cost Evaluation (PRICE) Trial. Am Heart J 2001; 141:402.
- ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy. Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. Lancet 2000; 356:2037.
- Kabbani SS, Aggarwal A, Terrien EF, et al. Suboptimal early inhibition of platelets by treatment with tirofiban and implications for coronary interventions. Am J Cardiol 2002; 89:647.
- Bolognese L, Falsini G, Liistro F, et al. Randomized comparison of upstream tirofiban versus downstream high bolus dose tirofiban or abciximab on tissue-level perfusion and troponin release in high-risk acute coronary syndromes treated with percutaneous coronary interventions: the EVEREST trial. J Am Coll Cardiol 2006; 47:522.
- Valgimigli M, Percoco G, Barbieri D, et al. The additive value of tirofiban administered with the high-dose bolus in the prevention of ischemic complications during high-risk coronary angioplasty: the ADVANCE Trial. J Am Coll Cardiol 2004; 44:14.
- Popma JJ, Weitz J, Bittl JA, et al. Antithrombotic therapy in patients undergoing coronary angioplasty. Chest 1998; 114:728S.
- Chew DP, Bhatt DL, Lincoff AM, et al. Defining the optimal activated clotting time during percutaneous coronary intervention: aggregate results from 6 randomized, controlled trials. Circulation 2001; 103:961.
- Hirsh J, Warkentin TE, Raschke R, et al. Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and safety. Chest 1998; 114:489S.
- Oltrona L, Eisenberg PR, Lasala JM, et al. Association of heparin-resistant thrombin activity with acute ischemic complications of coronary interventions. Circulation 1996; 94:2064.
- Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:e574.
- Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1.
- Schulz S, Mehilli J, Neumann FJ, et al. ISAR-REACT 3A: a study of reduced dose of unfractionated heparin in biomarker negative patients undergoing percutaneous coronary intervention. Eur Heart J 2010; 31:2482.
- Tolleson TR, O'Shea JC, Bittl JA, et al. Relationship between heparin anticoagulation and clinical outcomes in coronary stent intervention: observations from the ESPRIT trial. J Am Coll Cardiol 2003; 41:386.
- EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 1997; 336:1689.
- Brener SJ, Moliterno DJ, Lincoff AM, et al. Relationship between activated clotting time and ischemic or hemorrhagic complications: analysis of 4 recent randomized clinical trials of percutaneous coronary intervention. Circulation 2004; 110:994.
- www.acc.org/qualityandscience/clinical/statements.htm (accessed September 18, 2007) www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).
- Popma JJ, Berger P, Ohman EM, et al. Antithrombotic therapy during percutaneous coronary intervention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:576S.
- Rabah M, Mason D, Muller DW, et al. Heparin after percutaneous intervention (HAPI): a prospective multicenter randomized trial of three heparin regimens after successful coronary intervention. J Am Coll Cardiol 1999; 34:461.
- Friedman HZ, Cragg DR, Glazier SM, et al. Randomized prospective evaluation of prolonged versus abbreviated intravenous heparin therapy after coronary angioplasty. J Am Coll Cardiol 1994; 24:1214.
- Bhatt DL, Lee BI, Casterella PJ, et al. Safety of concomitant therapy with eptifibatide and enoxaparin in patients undergoing percutaneous coronary intervention: results of the Coronary Revascularization Using Integrilin and Single bolus Enoxaparin Study. J Am Coll Cardiol 2003; 41:20.
- Linkins LA, Julian JA, Rischke J, et al. In vitro comparison of the effect of heparin, enoxaparin and fondaparinux on tests of coagulation. Thromb Res 2002; 107:241.
- Henry TD, Satran D, Knox LL, et al. Are activated clotting times helpful in the management of anticoagulation with subcutaneous low-molecular-weight heparin? Am Heart J 2001; 142:590.
- Cavender MA, Sabatine MS. Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: a meta-analysis of randomised controlled trials. Lancet 2014; 384:599.
- Vandvik PO, Lincoff AM, Gore JM, et al. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e637S.
- OUR APPROACH
- P2Y12 RECEPTOR BLOCKERS
- Evidence regarding timing and dose
- Patients already taking clopidogrel
- Possible coronary artery bypass graft surgery
- Problems with clopidogrel use
- GP IIb/IIIa INHIBITORS
- Risk for bleeding
- Choice of agent
- - Dosing and monitoring
- - Use with GP IIb/IIIa inhibitors
- - Postprocedural management
- - Heparin-induced thrombocytopenia
- PATIENTS TAKING LONG-TERM ORAL ANTICOAGULATION
- PATIENTS UNDERGOING BALLOON ANGIOPLASTY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS