The optimal management of patients on oral anticoagulation undergoing coronary artery stenting

 

 Buy Article Permissions and Reprints

Summary

Even 10 years after the first appearance in the literature of articles reporting on the management of patients on oral anticoagulation (OAC) undergoing percutaneous coronary intervention with stent (PCI-S), this issue is still controversial. Nonetheless, some guidance for the everyday management of this patient subset, accounting for about 5–8 % of all patients referred for PCI-S, has been developed. In general, a period of triple therapy (TT) of OAC, with either vitamin K–antagonists (VKA) or non-vitamin K–antagonist oral anticoagulants (NOAC), aspirin, and clopidogrel is warranted, followed by the combination of OAC, and a single antiplatelet agent for up to 12 months, and then OAC alone. The duration of the initial period of TT is dependent on the individual risk of thromboembolism, and bleeding, as well as the clinical context in which PCI-S is performed (elective vs acute coronary syndrome), and the type of stent implanted (bare-metal vs drug-eluting). In this article, we aim to provide a comprehensive, ata- glance, overview of the management strategies, which are currently suggested for the peri-procedural, medium-term, and long-term periods following PCI-S in OAC patients. While acknowledging that most of the evidence has been obtained from patients on OAC because of atrial fibrillation, and with warfarin being the most frequently used VKA, we refer in this overview to the whole population of OAC patients undergoing PCI-S. We refer to the whole population of patients on OAC undergoing PCI-S also when OAC is carried out with NOAC rather than VKA, pointing out, when appropriate, the particular management issues.

Note: The review process for this paper was fully handled by Christian Weber, Editor-in-Chief.

• References

• 1 Orford JL, Fasseas P, Melby S. et al. Safety and efficacy of aspirin, clopidogrel, and warfarin after coronary stent placement in patients with an indication for anticoagulation. Am Heart J 2004; 147: 463-467.
  CrossrefPubMedGoogle Scholar
• 2 Rubboli A, Colletta M, Sangiorgio P. et al. Antithrombotic treatment after coronary artery stenting in patients on chronic oral anticoagulation: an international survey of current clinical practice. Ital Heart J 2004; 05: 851-856.
  PubMedGoogle Scholar
• 3 Rubboli A, Colletta M, Sangiorgio P. et al. Antithrombotic strategies in patients with an indication for long-term anticoagulation undergoing coronary artery stenting: safety and efficacy data from a single center. Ital Heart J 2004; 05: 919-925.
  PubMedGoogle Scholar
• 4 Rubboli A, Halperin JL, Airaksinen KE. et al. Antithrombotic therapy in patients treated with oral anticoagulation undergoing coronary artery stenting. An expert consensus document with focus on atrial fibrillation. Ann Med 2008; 40: 428-436.
  CrossrefPubMedGoogle Scholar
• 5 Lip GY, Huber K, Andreotti F. et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting. A Consensus Document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association [EHRA] and the European Association of Percutaneous Cardiovascular Interventions [EAPCI]. Thromb Haemost 2010; 103: 13-28.
  Article in Thieme ConnectPubMedGoogle Scholar
• 6 Faxon DP, Eikelboom JW, Berger PB. et al. Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective. Thromb Haemost 2011; 106: 572-584.
  Article in Thieme ConnectPubMedGoogle Scholar
• 7 Lip GY, Windecker S, Huber K. et al. Management of Antithrombotic Therapy in Atrial Fibrillation Patients Presenting With Acute Coronary Syndrome and/or Undergoing Percutaneous Coronary or Valve Interventions: A joint Consensus Document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association [EHRA], European Association of Percutaneous Cardiovascular Interventions [EAPCI] and European Association of Acute Cardiac Care [ACCA]. Endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J. 2014 in press.
  PubMedGoogle Scholar
• 8 Karjalainen PP, Vikman S, Niemelä M. et al. Safety of percutaneous coronary intervention during uninterrupted oral anticoagulant treatment. Eur Heart J 2008; 29: 1001-1010.
  CrossrefPubMedGoogle Scholar
• 9 Lahtela H, Rubboli A, Schlitt A. et al.; AFCAS (Management of patients with Atrial Fibrillation undergoing Coronary Artery Stenting) study group. Heparin bridging vs uninterrupted oral anticoagulation in patients with Atrial Fibrillation undergoing Coronary Artery Stenting. Results from the AFCAS registry. Circ J 2012; 76: 1363-1368.
  CrossrefPubMedGoogle Scholar
• 10 Dewilde WJ, Janssen PW, Kelder JC. et al. Uninterrupted oral anticoagulation versus bridging in patients with long-term oral anticoagulation during percutaneous coronary intervention: subgroup analysis from the WOEST trial. Eurointervention. 2014 Epub ahead of print.
  PubMedGoogle Scholar
• 11 Douketis JD, Spyropoulos A, Spencer FA. et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th edition: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 141: e326S-e350S.
  CrossrefPubMedGoogle Scholar
• 12 Pancholy SB, Ahmed I, Bertrand OF. et al. Frequency of radial artery occlusion after transradial access in patients receiving warfarin therapy and undergoing coronary angiography. Am J Cardiol 2014; 113: 211-214.
  CrossrefPubMedGoogle Scholar
• 13 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: 30-35.
  CrossrefPubMedGoogle Scholar
• 14 Heidbüchel H, Verhamme P, Alings M. et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013; 15: 625-651.
  CrossrefPubMedGoogle Scholar
• 15 Vranckx P, Verheugt FW, de Maat MP. et al. A randomised study of dabigatran in elective percutaneous coronary intervention in stable coronary artery disease patients. Eurointervention 2013; 08: 1052-1060.
  CrossrefPubMedGoogle Scholar
• 16 Ziakas AG, Koskinas KC, Gavrilidis S. et al. Radial versus femoral access for orally anticoagulated patients. Catheter Cardiovasc Interv 2010; 76: 493-499.
  CrossrefPubMedGoogle Scholar
• 17 Hamon M, Pristipino C, Di Mario C. et al.; European Association of Percutaneous Cardiovascular Interventions. Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology. Eurointervention 2013; 08: 1242-1251.
  CrossrefPubMedGoogle Scholar
• 18 Windecker S, Kolh P, Alfonso F. et al. 2014 ESC/EACTS Guidelines on myocardial revascularisation. The Task Force on Myocardial Revascularisation of the European Society of Cardiology (ESC) and European Association of CardioThoracic Surgery. Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35: 2541-2619.
  CrossrefPubMedGoogle Scholar
• 19 Palmerini T, Biondi-Zoccai G, Della Riva D. et al. Stent thrombosis with drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. Lancet 2012; 379: 1393-1402.
  CrossrefPubMedGoogle Scholar
• 20 Silber S, Kirtane AJ, Belardi JA. et al. Lack of association between dual antiplatelet therapy use and stent thrombosis between 1 and 12 months following resolute zotarolimus-eluting stent implantation. Eur Heart J 2014; 35: 1949-1956.
  CrossrefPubMedGoogle Scholar
• 21 King 3rd SB, Smith Jr, SC, Hirshfeld Jr, JW. et al. 2007 focused update of the 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: (2007 Writing Group To Review New Evidence and Update the 2005 ACC/AHA/SCAI Guideline Update for Percutaneous Coronary Intervention. Circulation 2008; 117: 265-291.
  PubMedGoogle Scholar
• 22 Lahtela H, Karjalainen PP, Niemelä M. et al. Are glycoprotein inhibitors safe during percutaneous coronary intervention in patients on chronic warfarin treatment?. Thromb Haemost 2009; 102: 1227-1233.
  Article in Thieme ConnectPubMedGoogle Scholar
• 23 Stone GW, Witzenbichler B, Guagliumi G. et al.; HORIZONS-AMI Trial Investigators. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med 2008; 358: 2218-2230.
  CrossrefPubMedGoogle Scholar
• 24 Kiviniemi T, Karjalainen P, Niemelä M. et al. Bivalirudin use during percutaneous coronary intervention in patients on chronic warfarin therapy. Thromb Res 2014; 133: 695-696.
  CrossrefPubMedGoogle Scholar
• 25 Bangalore S, Amoroso N, Fusaro M. et al. Outcomes with various drug-eluting or bare metal stents in patients with ST-elevation myocardial infarction: a mixed treatment comparison analysis of trial level data from 34068 patient-years of follow-up from randomized trials. Catheter Cardiovasc Interv 2013; 06: 378-390.
  CrossrefPubMedGoogle Scholar
• 26 Wiviott SD, Braunwald E, McCabe CH. et al.; TRITON TIMI-38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007; 357: 2001-2015.
  CrossrefPubMedGoogle Scholar
• 27 Wallentin L, Becker RC, Budaj A. et al.; PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009; 361: 1045-1057.
  CrossrefPubMedGoogle Scholar
• 28 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: 2060-2066.
  CrossrefPubMedGoogle Scholar
• 29 Bernard A, Fauchier L, Pellegrin C. et al. Anticoagulation in patients with atrial fibrillation undergoing coronary stent implantation. Thromb Haemost 2013; 110: 560-568.
  Article in Thieme ConnectPubMedGoogle Scholar
• 30 Azoulay L, Dell’Aniello S, Simon T. et al. The concurrent use of antithrombotic therapies and the risk of bleeding in patients with atrial fibrillation. Thromb Haemost 2013; 109: 431-439.
  Article in Thieme ConnectPubMedGoogle Scholar
• 31 Dans AL, Connolly SJ, Wallentin L. et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation 2013; 127: 634-640.
  CrossrefPubMedGoogle Scholar
• 32 De Caterina R, Husted S, Wallentin L. et al. Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis-Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2013; 110: 1087-1107.
  Article in Thieme ConnectPubMedGoogle Scholar
• 33 Gallego P, Roldan V, Marín F. et al. Cessation of oral anticoagulation in relation to mortality and the risk of thrombotic events in patients with atrial fibrillation. Thromb Haemost 2013; 110: 1189-1198.
  Article in Thieme ConnectPubMedGoogle Scholar
• 34 Bhatt DL, Scheiman J, Abraham NS. et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2008; 52: 1502-1517.
  CrossrefPubMedGoogle Scholar
• 35 Desai J, Kolb JM, Weitz JI. et al. Gastrointestinal bleeding with the new oral anticoagulants - defining the issues and the management strategies. Thromb Hae-most 2013; 110: 205-212.
  Article in Thieme ConnectPubMedGoogle Scholar
• 36 Dewilde WJ, Oirbans T, Verheugt FW. et al.; WOEST study investigators. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381: 1107-1115.
  CrossrefPubMedGoogle Scholar
• 37 Lamberts M, Gislason GH, Olesen JB. et al. Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. J Am Coll Cardiol 2013; 62: 981-989.
  CrossrefPubMedGoogle Scholar
• 38 Rubboli A, Schlitt A, Kiviniemi T. et al.; AFCAS Study Group. One-year outcome of patients with atrial fibrillation undergoing coronary artery stenting: an analysis of the AFCAS registry. Clin Cardiol 2014; 37: 357-364.
  CrossrefPubMedGoogle Scholar
• 39 Rubboli A, Saia F, Sciahbasi A. et al; WAR-STENT Study Group. Outcome of patients on oral anticoagulation undergoing coronary artery stenting: data from discharge to 12 months in the WARfarin and coronary STENTing (WARSTENT) Registry. J Invasive Cardiol. 2014 in press.
  PubMedGoogle Scholar
• 40 US National Institutes of Health, ClinicalTrials.gov.. A study exploring two strategies of rivaroxaban (JNJ39039039; BAY-59-7939) and one of oral vitamin K antagonist in patients with atrial fibrillation who undergo percutaneous coronary intervention. http//clinicaltrials.gov/ct2/show Accessed August 14, 2014.
  PubMedGoogle Scholar
• 41 US National Institutes of Health, ClinicalTrials.gov.. Evaluation of dual therapy with dabigatran vs triple therapy with warfarin in patients with AF who undergo PCI with stenting (RE-DUAL PCI). http//clinicaltrials.gov/ct2/show Accessed August 14, 2014.
  PubMedGoogle Scholar
• 42 Rubboli A, Milandri M, Castelvetri C. et al. Meta-analysis of trials comparing oral anticoagulation and aspirin versus dual antiplatelet therapy after coronary stenting. Clues for the management of patients with an indication for long-term anticoagulation undergoing coronary stenting. Cardiology 2005; 104: 101-106.
  CrossrefPubMedGoogle Scholar
• 43 Karjalainen PP, Porela P, Ylitalo A. et al. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J 2007; 28: 726-732.
  CrossrefPubMedGoogle Scholar
• 44 Hurlen M, Abdelnoor M, Smith P. et al. Warfarin, aspirin, or both after myocardial infarction. N Engl J Med 2002; 347: 969-974.
  CrossrefPubMedGoogle Scholar
• 45 Sørensen R, Hansen ML, Abildstrom SZ. et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet 2009; 374: 1967-1974.
  CrossrefPubMedGoogle Scholar
• 46 Douxfils J, Buckinx F, Mullier F. et al. Dabigatran etexilate and risk of myocardial infarction, other cardiovascular events, major bleeding, and all-cause mortality: a systematic review and meta-analysis of randomized controlled trials. J Am Heart Assoc 2014; 03: e000515.
  CrossrefPubMedGoogle Scholar