Management of antithrombotic therapy in patients receiving long-term oral anticoagulation undergoing percutaneous coronary intervention
- David R Holmes, Jr, MD
David R Holmes, Jr, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
- Nikolaus Sarafoff, MD
Nikolaus Sarafoff, MD
- Klinikum der Ludwig Maximilians Universität
- Munich, Germany
- Section Editors
- Stephan Windecker, MD
Stephan Windecker, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Department of Cardiology
- Bern University Hospital
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
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".)
DEFINING THE ISSUES
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 . All-cause mortality was 23 percent.
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- 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.
- 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.
- 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.
- DEFINING THE ISSUES
- DUAL ANTIPLATELET THERAPY
- PREPROCEDURAL ANTICOAGULANT MANAGEMENT
- Urgent patients
- Elective patients
- INTRAPROCEDURAL ANTICOAGULANT MANAGEMENT
- Access site
- Stent type
- Use of GP IIb/IIIa inhibitors
- POSTPROCEDURAL ANTICOAGULANT MANAGEMENT
- PERIPROCEDURAL BLEEDING
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS