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Periprocedural and medium-term antithrombotic strategies in patients with an indication for long-term anticoagulation
Andrea Rubboli1, Mauro Colletta, Jessica Herzfeld
1Division of Cardiology, Maggiore Hospital, Bologna, Italy, and School of Medicine, Karolinska University, Stockholm, Sweden. andrearubboli@libero.it
Insights
Optimal antithrombotic therapy for patients on long-term anticoagulation undergoing percutaneous coronary intervention with stent implantation remains undefined. Variable strategies showed a significant 1-month complication rate, necessitating further research for optimal treatment protocols.
Area of Science:
- Cardiology
- Thrombosis Research
- Interventional Cardiology
Background:
- Optimal antithrombotic treatment for patients on long-term anticoagulation undergoing invasive coronary procedures is undefined.
- Current strategies for periprocedural and medium-term management after coronary stenting vary significantly.
- This study reviews institutional practices and evaluates the safety and efficacy of different antithrombotic regimens.
Purpose of the Study:
- To review and evaluate antithrombotic strategies in patients on long-term anticoagulation undergoing percutaneous coronary intervention with stent implantation.
- To assess the safety and efficacy of various periprocedural and medium-term antithrombotic regimens.
- To identify the need for standardized protocols in this growing patient population.
Main Methods:
- Retrospective identification of all patients undergoing invasive coronary procedures between January 2002 and December 2004.
- Analysis of antithrombotic strategies, including warfarin withdrawal/substitution and post-procedural antiplatelet therapy.
- Evaluation of periprocedural and 1-month complication rates (hemorrhage and thromboembolism).
Main Results:
- Of 3709 patients, 104 (2.8%) were on warfarin; 49 (3.1%) of 1584 undergoing PCI with stenting were on warfarin.
- Antithrombotic strategies were highly variable, with mixed periprocedural and medium-term treatments.
- A 1-month hemorrhagic rate of 10% was observed, primarily during triple therapy (warfarin/LMWH, aspirin, thienopyridine). No thromboembolic events were noted, but one subacute stent thrombosis occurred.
Conclusions:
- Antithrombotic treatment in patients on long-term anticoagulation undergoing PCI with stenting demonstrated substantial variability at the institution.
- The observed 1-month complication rate highlights the need for further research.
- Properly designed studies are warranted to establish optimal antithrombotic strategies for this patient subset.
Objectives:
The optimal antithrombotic treatment for patients on long-term anticoagulation undergoing invasive coronary procedures is currently undefined. The strategies adopted periprocedurally and medium-term after coronary stenting (percutaneous coronary intervention with stent implantation) at our Institution, were reviewed, and the safety and efficacy of the various regimens evaluated.
Methods:
All patients undergoing invasive coronary procedures between January 2002 and December 2004 were retrospectively identified.
Results:
Out of 3709 patients overall, 104 (2.8%; 95% confidence interval 2.3-3.4) were on warfarin (because of atrial fibrillation in >50% of cases), whereas this was the case for 49 (3.1%; 95% confidence interval 2.3-4.1) of 1584 undergoing percutaneous coronary intervention with stent implantation. The antithrombotic strategies were highly variable, both periprocedurally (i.e. warfarin withdrawal or substitution by heparin, followed by aspirin with or without a thienopyridine) and medium-term after percutaneous coronary intervention with stent implantation (i.e. combination of warfarin and single or dual antiplatelet agents or pure dual antiplatelet treatment). Overall, periprocedural hemorrhages occurred in five patients (4.8%; 95% confidence interval 1.56-11.22). No thromboembolic events were observed, whereas one subacute stent thrombosis occurred (2%; 95% confidence interval 0.05-11) during warfarin and aspirin treatment. Among patients undergoing percutaneous coronary intervention with stent implantation, 1-month hemorrhagic rate was 10% (95% confidence interval, 3.3-23.8); most hemorrhages (major bleeds in three-quarters of cases) occurred during triple therapy with warfarin (or low-molecular-weight heparin), aspirin and a thienopyridine.
Conclusions:
At our Institution (where standardized protocols are currently not in use), periprocedural and medium-term antithrombotic treatment in patients on long-term anticoagulation undergoing percutaneous coronary intervention with stent implantation showed substantial variability. As a result of the relevant 1-month complication rate, further properly sized and designed studies are warranted to identify the optimal strategies for this patient subset, which is foreseen to progressively increase over the next years.
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