Antithrombotic management of patients on oral anticoagulation undergoing coronary artery stenting

Patients on oral anticoagulation (OAC), who are referred for coronary artery stenting account for about 5% of the whole population undergoing percutaneous coronary intervention (PCI). Although relatively small, this patient subset poses particular problems owing to the need to balance carefully the risk of bleeding against the risk of stent thrombosis and thromboembolism. Triple therapy (TT) of OAC, aspirin and clopidogrel appears as the most effective for prevention of stent thrombosis and thromboembolism. However, an increased incidence of major bleeding is to be expected during follow-up. Therefore, TT should be prolonged for as short a time as possible, and implantation of drug-eluting stents avoided. Frequent monitoring of international normalized ratio is also warranted, and the intensity of OAC should be targeted at the lower limit of the therapeutic range. Gastric protection should also be considered for all patients on medium- to long-term TT, owing to the observed highest incidence of bleeding at the gastrointestinal site. Peri-procedural management is cumbersome, and a substantial incidence of in-hospital major bleeding has been reported. Since this latter is more related to procedural variables than to TT itself, choice of radial access, avoidance of glycoprotein IIb/IIIa inhibitors, and preference for not interrupting effective OAC should be implemented. However, the evidence on which the recommendations for managing this patient subset are based is limited and of relative poor quality. While waiting for the results of ongoing, large prospective studies that are aimed at conclusively determining optimal medium- to long-term antithrombotic treatment, the official recommendations issued by the Working Group on Thrombosis of the European Society of Cardiology on the management of patients on OAC undergoing PCI with stenting should followed.