Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Management of antithrombotic therapy in patients receiving long-term oral anticoagulation undergoing percutaneous coronary intervention

David R Holmes, Jr, MD
Nikolaus Sarafoff, MD
Section Editors
Stephan Windecker, MD
Donald Cutlip, MD
Deputy Editor
Gordon M Saperia, MD, FACC


All patients who undergo percutaneous coronary intervention (PCI) are at risk of periprocedural bleeding, a complication that results from the combination of vascular puncture and periprocedural antithrombotic therapy, the latter of which generally includes aspirin, a P2Y12 receptor blocker, and a parenteral anticoagulant. This bleeding risk is further increased in any patient receiving chronic anticoagulant therapy. Approximately 5 percent of patients undergoing PCI are treated with long-term oral anticoagulation (OAC) for conditions such as atrial fibrillation, venous thromboembolism, or prior placement of a mechanical heart valve [1,2]. (See "Antithrombotic therapy for prosthetic heart valves: Management of bleeding and invasive procedures", section on 'Cardiac catheterization'.)

The optimal periprocedural antithrombotic strategy in these patients depends on the relative risks of thrombosis in patients who have their anticoagulant temporarily stopped and bleeding risk if it is continued. These risks are also impacted by whether the patient is undergoing an elective or urgent procedure (eg, acute coronary syndrome).

This topic discusses issues surrounding the periprocedural management of antithrombotic therapy in patients on OAC undergoing PCI. The issues surrounding the care of patients who are candidates for longer-term dual antiplatelet therapy and anticoagulant therapy are discussed separately. (See "Triple antithrombotic therapy in patients with cardiovascular disease".)


The management of periprocedural antithrombotic therapy in patients undergoing percutaneous coronary intervention (PCI) is challenging because of the competing risks of thrombosis and bleeding. Interrupting anticoagulation for this procedure transiently increases the risk of periprocedural thromboembolism while continuing anticoagulant therapy may increase the risk of periprocedural bleeding. In addition, if the patient has a bleeding complication, the anticoagulant is often discontinued for a variable length of time, resulting in a longer period of increased thromboembolic risk. (See "Periprocedural bleeding in patients undergoing percutaneous coronary intervention".)

It is estimated that 5 to 10 percent of patients referred for PCI have a strong indication for long-term anticoagulation, with atrial fibrillation (AF) being the most common [3-6]. AF patients who undergo coronary stenting are at high risk of adverse events due to frequent comorbidities. In a report of 426 such patients, a major adverse cardiovascular event (death, myocardial infarction, or target lesion revascularization) rate of 32 percent at a median follow-up of 595 days after PCI were seen [7]. All-cause mortality was 23 percent.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jul 12, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Schömig A, Sarafoff N, Seyfarth M. Triple antithrombotic management after stent implantation: when and how? Heart 2009; 95:1280.
  2. Holmes DR Jr, Kereiakes DJ, Kleiman NS, et al. Combining antiplatelet and anticoagulant therapies. J Am Coll Cardiol 2009; 54:95.
  3. Hylek EM, Solarz DE. Dual antiplatelet and oral anticoagulant therapy: increasing use and precautions for a hazardous combination. JACC Cardiovasc Interv 2008; 1:62.
  4. Karjalainen PP, Porela P, Ylitalo A, et al. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J 2007; 28:726.
  5. Rubboli A, Colletta M, Valencia J, et al. Periprocedural management and in-hospital outcome of patients with indication for oral anticoagulation undergoing coronary artery stenting. J Interv Cardiol 2009; 22:390.
  6. Wang TY, Robinson LA, Ou FS, et al. Discharge antithrombotic strategies among patients with acute coronary syndrome previously on warfarin anticoagulation: physician practice in the CRUSADE registry. Am Heart J 2008; 155:361.
  7. Ruiz-Nodar JM, Marín F, Hurtado JA, et al. Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis. J Am Coll Cardiol 2008; 51:818.
  8. Sarafoff N, Martischnig A, Wealer J, et al. Triple therapy with aspirin, prasugrel, and vitamin K antagonists in patients with drug-eluting stent implantation and an indication for oral anticoagulation. J Am Coll Cardiol 2013; 61:2060.
  9. Jackson LR 2nd, Ju C, Zettler M, et al. Outcomes of Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention Receiving an Oral Anticoagulant and Dual Antiplatelet Therapy: A Comparison of Clopidogrel Versus Prasugrel From the TRANSLATE-ACS Study. JACC Cardiovasc Interv 2015; 8:1880.
  10. Beyer-Westendorf J, Gelbricht V, Förster K, et al. Peri-interventional management of novel oral anticoagulants in daily care: results from the prospective Dresden NOAC registry. Eur Heart J 2014; 35:1888.
  11. Sticherling C, Marin F, Birnie D, et al. Antithrombotic management in patients undergoing electrophysiological procedures: a European Heart Rhythm Association (EHRA) position document endorsed by the ESC Working Group Thrombosis, Heart Rhythm Society (HRS), and Asia Pacific Heart Rhythm Society (APHRS). Europace 2015; 17:1197.
  12. Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med 2013; 368:2084.
  13. Jamula E, Lloyd NS, Schwalm JD, et al. Safety of uninterrupted anticoagulation in patients requiring elective coronary angiography with or without percutaneous coronary intervention: a systematic review and metaanalysis. Chest 2010; 138:840.
  14. Kiviniemi T, Karjalainen P, Pietilä M, et al. Comparison of additional versus no additional heparin during therapeutic oral anticoagulation in patients undergoing percutaneous coronary intervention. Am J Cardiol 2012; 110:30.
  15. Schulz-Schüpke S, Helde S, Gewalt S, et al. Comparison of vascular closure devices vs manual compression after femoral artery puncture: the ISAR-CLOSURE randomized clinical trial. JAMA 2014; 312:1981.
  16. Authors/Task Force members, Windecker S, Kolh P, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541.
  17. Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17:1467.