Antithrombotic Therapy Use After Percutaneous Coronary Intervention and Stent Implantation in Patients Taking Chronic Oral Anticoagulation
Juan M. Ruiz-Nodar, MD, PhD,
Francisco Marín, MD, PhD,
Gregory Y.H. Lip, MD*
The recent study by Rogacka et al. (1) evaluates the safety of dual antiplatelet therapy in patients in whom long-term anticoagulation (AC) with warfarin is recommended. They conclude that major bleeding occurred in 4.7% (n = 6 only), in which half were lethal, and most occurred within the first month.
Rogacka et al. (1) address a growing management problem given that more patients who require AC may have to undergo percutaneous coronary intervention (PCI) with stenting. Unfortunately, there is limited published evidence on the optimal antithrombotic management strategy in such patients. No antithrombotic strategies have been tested in large prospective randomized controlled trials, and we may never have this information because of the complexity of this population, which would make the randomization to different antithrombotic therapy strategies very difficult. Thus, registry series such as that of Rogacka et al. (1) achieve more relevance given that such data may inform the optimal strategy for such patients.
The most important limitation of their study (1) is the small number of patients (n = 127), which could prevent us from really seeing the true complication rate derived from triple therapy, and this could partly explain the low rate of major bleeding seen (4.7%). In addition, Rogacka et al. (1) have a heterogeneous study population in which atrial fibrillation (AF) was the main indication for AC (in 59.1%), and venous thromboembolism, left ventricular mural thrombus, and prosthetic valves were other indications for AC. Clearly, the stroke and thromboembolic risk for an AF patient, as well as associated comorbidities and concomitant drug therapies, may be quite different from that seen with venous thromboembolism.
As far as we are aware, there have only been 2 published series of antithrombotic therapy in patients with (exclusively) AF undergoing PCI (2,3). Our series of 426 patients with AF treated with PCI/stent is the largest published dataset to date, and of this cohort, 50% were treated with triple therapy (3). Complete follow-up was achieved in 88% with a median of 595 days, and major bleeding occurred in 14.9%, with death in 17.8% and major adverse cardiac events in 26.5%. We concluded that patients with AF undergoing PCI with stenting represent a high-risk population with a high mortality and major adverse cardiovascular event rates, which are importantly reduced by AC.
The rate of major bleeding in our report (3) is consistent with that in other series, for example, those from Orford et al. (4) (9.2%) or Karjalainen et al. (5) (8.2%), and may reflect the longer follow-up in our series. The lower rate of major bleeding and serious adverse events in the paper by Rogacka et al. (1) also could be explained by other important limitations, including the heterogeneous study population with different indications for AC therapy, obvious differences underlying comorbidities, and a low risk of acute cardiac events (e.g., acute coronary syndrome in 25.9% vs. 83.9% in our series).
We would agree with Rogacka et al. (1) that triple therapy could probably be a good therapeutic option in patients with AF who undergo PCI/stent implantation—at least in the initial period—but we are less optimistic about the long-term risks (mainly hemorrhagic) with such a strategy. We strongly suggest that the post-PCI strategy should be tailored to the individual patient and their risk of stroke/thromboembolism, but balancing the risk of stent thrombosis against their risk of bleeding while receiving such triple therapy (2).
* University Department of Medicine, City Hospital, Birmingham B18 7QH, England (Email: g.y.h.lip{at}bham.ac.uk).
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REFERENCES
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- Rogacka R, Chieffo A, Michev I, et al. Dual antiplatelet therapy after percutaneous coronary intervention with stent implantation in patients taking chronic oral anticoagulation J Am Coll Cardiol Intv 2008;1:56-61.[Abstract/Free Full Text]
- Lip GY, Karpha M. Anticoagulant and antiplatelet therapy use in patients with atrial fibrillation undergoing percutaneous coronary intervention: the need for consensus and a management guideline Chest 2006;130:1823-1827.[CrossRef][Web of Science][Medline]
- Ruiz-Nodar JM, Marín F, Hurtado JA, et al. Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary interventions and stent implantation J Am Coll Cardiol 2008;51:818-825.[Abstract/Free Full Text]
- 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.[CrossRef][Web of Science][Medline]
- 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.[Abstract/Free Full Text]
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REFERENCES