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Post-procedural Anticoagulation With Unfractionated Heparin in Acute Coronary Syndrome: Insight from the STOPDAPT-3
Hirotoshi Watanabe1, Masahiro Natsuaki2, Takeshi Morimoto3
1Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan.
Insights
Post-percutaneous coronary intervention (PCI) heparin use in acute coronary syndrome (ACS) patients increases bleeding risk without cardiovascular benefit. This analysis of the STOPDAPT-3 trial suggests current guidelines may need re-evaluation regarding anticoagulation post-PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Current guidelines for acute coronary syndrome (ACS) discourage post-percutaneous coronary intervention (PCI) anticoagulation without specific indications, yet evidence is limited.
- The STOPDAPT-3 trial provides data to re-evaluate the necessity and safety of heparin administration following PCI in ACS patients.
Purpose of the Study:
- To compare 30-day outcomes between patients with ACS who received post-PCI heparin versus those who did not.
- To assess the impact of post-PCI heparin on bleeding and cardiovascular events in ACS patients undergoing PCI without mechanical support.
Main Methods:
- Post hoc analysis of the STOPDAPT-3 trial involving 4,088 ACS patients.
- Comparison of co-primary end points: Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding, and a composite cardiovascular end point (death, MI, stent thrombosis, stroke).
- Analysis stratified by post-PCI heparin administration, dose, and patient characteristics like ST-elevation myocardial infarction.
Main Results:
- Over 57% of ACS patients received post-PCI heparin, with higher rates in ST-elevation myocardial infarction and those with intraprocedural adverse findings.
- Post-PCI heparin was associated with a significantly increased risk of bleeding (4.75% vs 2.52%, aHR 1.69) and a numerically increased cardiovascular event risk (3.16% vs 1.72%, aHR 1.56).
- Higher heparin doses correlated with increased incidence of both bleeding and cardiovascular events within 30 days.
Conclusions:
- Post-PCI anticoagulation with unfractionated heparin is common in ACS patients but associated with increased bleeding risk.
- Heparin use post-PCI in ACS patients did not demonstrate a benefit in reducing cardiovascular events, suggesting potential harm.
- Findings challenge current guidelines and highlight the need for evidence-based reassessment of post-PCI anticoagulation strategies in ACS.
Abstract:
The current guidelines for acute coronary syndrome (ACS) discourage the use of anticoagulation after percutaneous coronary intervention (PCI) without specific indications, although the recommendation is not well supported by evidence. In this post hoc analysis of the ShorT and OPtimal Duration of Dual AntiPlatelet Therapy-3 (STOPDAPT-3) trial, 30-day outcomes were compared between the 2 groups with and without post-PCI heparin administration among patients with ACS who did not receive mechanical support devices. The co-primary end points were the bleeding end point, defined as the Bleeding Academic Research Consortium type 3 or 5 bleeding, and the cardiovascular end point, defined as a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke. Among 4,088 patients with ACS, 2,339 patients (57.2%) received post-PCI heparin. The proportion of patients receiving post-PCI heparin was higher among those with ST-elevation myocardial infarction compared with others (72.3% and 38.8%, p <0.001), and among patients with intraprocedural adverse angiographic findings compared with those without (67.6% and 47.5%, p <0.001). Post-PCI heparin compared with no post-PCI heparin was associated with a significantly increased risk of the bleeding end point (4.75% and 2.52%, adjusted hazard ratio 1.69, 95% confidence interval 1.15 to 2.46, p = 0.007) and a numerically increased risk of the cardiovascular end point (3.16% and 1.72%, adjusted hazard ratio 1.56, 95% confidence interval 0.98 to 2.46, p = 0.06). Higher hourly dose or total doses of heparin were also associated with higher incidence of both bleeding and cardiovascular events within 30 days. In conclusion, post-PCI anticoagulation with unfractionated heparin was frequently implemented in patients with ACS. Post-PCI heparin use was associated with harm in terms of increased bleeding without the benefit of reducing cardiovascular events. Trial identifier: STOPDAPT-3 ClinicalTrials.gov number, NCT04609111.
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