Antithrombotic Therapy in Complex Percutaneous Coronary Intervention Patients Requiring Chronic Anticoagulation

The optimal antithrombotic treatment in patients receiving oral anticoagulation undergoing percutaneous coronary intervention (PCI) has been a field of intensive research. Although triple antithrombotic therapy had been, until lately, the strategy of choice, recent evidence points to the superiority of dual antithrombotic therapy regarding bleeding prevention, without significantly compromising efficacy. In the further challenging scenario of complex PCI, associated with a higher ischemic risk, the efficacy of an aspirin-free strategy, adopted shortly after the index event is under question, rendering decision-making a fairly difficult scenario for clinicians. Since patients with an indication for oral anticoagulation undergoing complex PCI are underrepresented in randomized trials, there are scarce data regarding the optimal treatment strategy in such patients. This review aims to analyze and compare different approaches regarding the type and duration of antithrombotic regimens, focusing on both safety and efficacy outcomes, as well as to discuss recent guidelines’ suggestions regarding the therapeutic approach in patients receiving oral anticoagulation undergoing PCI procedures of increased complexity.

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Intracranial haemorrhages vs. stent thromboses with direct oral anticoagulant plus single antiplatelet agent or triple antithrombotic therapy: a meta-analysis of randomized trials in atrial fibrillation and percutaneous coronary intervention/acute coronary syndrome patients

EP Europace ◽

10.1093/europace/euz345 ◽

2020 ◽

Vol 22 (4) ◽

pp. 538-546 ◽

Cited By ~ 7

Author(s):

Mattia Galli ◽

Felicita Andreotti ◽

Italo Porto ◽

Filippo Crea

Keyword(s):

Atrial Fibrillation ◽

Percutaneous Coronary Intervention ◽

Antithrombotic Therapy ◽

Randomized Trials ◽

Coronary Intervention ◽

Direct Oral Anticoagulant ◽

Coronary Syndrome ◽

Thrombosis Risk ◽

Percutaneous Coronary ◽

Triple Antithrombotic Therapy

Abstract Aims To assess the efficacy-safety profile of dual antithrombotic therapy (DAT) including direct oral anticoagulant (DOAC) vs. triple antithrombotic therapy (TAT) in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Methods and results Randomized trials of AF patients with ACS/PCI, comparing DAT using DOACs against TAT, were selected. Overall, 11 161 studies were screened, 458 trials assessed, and four included, comprising 10 234 patients followed for a mean of 11 months. DAT compared to TAT resulted in significant reductions of trial-defined primary safety outcome [odds ratio (OR) 0.63, 95% confidence interval (CI) 0.50–0.79, number needed to treat (NNT) 17] and of thrombolysis in myocardial infarction (TIMI) major bleeding (OR 0.54, 95% CI 0.41–0.70, NNT 76) and in a numerical reduction of intracranial haemorrhage (OR 0.50, 95% CI 0.21–1.19, NNT 314), which became significant after exclusion of DOACs from TAT and vitamin K antagonist from DAT arms (OR 0.31, 95% CI 0.15–0.64). There were no significant differences in the risks of cardiovascular or any deaths or stroke, but with DAT, there was a numerical increase in myocardial infarctions (MIs) (OR 1.23, 95% CI 0.99–1.54, estimated NNT for an additional harmful outcome (NNTH) 151), which became significant in the ACS/PCI subgroup (OR 1.43, 95% CI 1.02–2.00), and a 60% significant increase in stent thrombosis risk (OR 1.60, 95% CI 1.02–2.52; NNTH 274). Conclusion Dual antithrombotic therapy, compared to TAT, conferred a significantly reduced risk of overall bleeding but with a significant increase of stent thrombosis risk in the overall population and a significant 43% increase of MI in the ACS/PCI subgroup.

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