Antithrombotic Strategies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

The optimal strategy of antithrombotic therapy for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention remains to be a question to be answered. The major challenge in such population is the balance between the benefit of reduced stroke and coronary ischemic events, against the risk of increased bleeding complications. Thus, both thrombotic and bleeding risk assessments should be included into clinical decision-making process for such patients. Currently, there is limited evidence based on randomized trials with adequate power to show the superiority of any strategy in the beneficial profile of safety and efficacy, thus limited recommendations are provided by clinical guidelines. Given the recent advancement in this field, our review provided an overview of the available risk stratification schemes for stroke and bleeding risk for AF patients, discussed the multiple questions in the optimal regimens of oral antiplatelet and anticoagulation therapy, and summarized evidence and recommendations related to long-term antithrombotic therapy for AF patients receiving stent implications.

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New antithrombotic strategies and coronary stent technologies for patients at high bleeding risk undergoing percutaneous coronary intervention

Current Vascular Pharmacology ◽

10.2174/1570161119666210809163404 ◽

2021 ◽

Vol 19 ◽

Author(s):

Sabato Sorrentino ◽

Nadia Salerno ◽

Isabella Leo ◽

Alberto Polimeni ◽

Jolanda Sabatino ◽

...

Keyword(s):

Decision Making ◽

Percutaneous Coronary Intervention ◽

Clinical Practice ◽

Clinical Decision Making ◽

Bleeding Risk ◽

Coronary Intervention ◽

Clinical Decision ◽

Review Article ◽

Percutaneous Coronary ◽

High Bleeding Risk

: Patients at high bleeding risk (HBR) are a sizable part of the population undergoing percutaneous coronary intervention (PCI) and stent implantation. This population historically lacks standardized definition, thus limiting trial design, data generalizability, and clinical decision-making. To overcome this limitation the Academic Research Consortium (ARC) has recently released comprehensive guidelines defining HBR criteria for study design purpose and daily clinical practice. Furthermore, several risk scores have been developed aiming to discriminate HBR patients and support physicians for clinical decision making when faced with this complex subset of patients. Accordingly, the first part of this review article will explore guideline-recommended risk scoring as well as ARC-HBR criteria and their relative application for daily clinical practice. The second part of this review article will explore the complex interplay between risk of bleeding, and coronary thrombotic events in patients deemed at HBR. Indeed, several features that identify these patients, are also independent predictors of recurrent ischemic events, thus challenging revascularization strategies and optimal antithrombotic therapy. Accordingly, several clinical trials have been conducted to evaluate the safety and efficacy of the new generation of coronary platforms and different antithrombotic strategies for HBR patients to minimize both ischemic and bleeding events. Accordingly, in this part we discuss current guidelines, trials and observational data evaluating antithrombotic strategies and stent technologies for patients at HBR.

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Could the PARIS Risk Scores Be Useful for the Choice of Triple vs Dual Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention?

Cardiology ◽

10.1159/000521673 ◽

2022 ◽

Author(s):

Leonardo De Luca ◽

Leonardo Bolognese ◽

Andrea Rubboli ◽

Donata Lucci ◽

Domenico Gabrielli ◽

...

Keyword(s):

Atrial Fibrillation ◽

Percutaneous Coronary Intervention ◽

Antithrombotic Therapy ◽

Bleeding Risk ◽

Daily Practice ◽

Coronary Intervention ◽

Risk Scores ◽

Thrombotic Risk ◽

Percutaneous Coronary ◽

Study Results

Introduction. Current guidelines recommend dual antithrombotic therapy (DAT) for the majority of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) and suggest a short course of triple antithrombotic therapy (TAT) for those at very high thrombotic risk (TR) but low bleeding risk (BR). Methods. We analyze if the PARIS ischemic-hemorrhagic scale could be useful for the choice of antithrombotic strategy in patients with acute coronary syndromes (ACS) and AF treated with coronary stenting enrolled in the prospective, observational, nationwide MATADOR-PCI study. Results. Among the 588 patients discharged alive, a TAT was prescribed in 381 (64.8%) and DAT in 52 (8.8%) patients. According to the PARIS scoring system, 142 (24.2%) were classified as low, 244 (41.5%) as intermediate and 292 (34.3%) as high TR. In parallel, 87 (14.8%) were categorized in the low, 260 (44.2%) in the intermediate and 241 (41.0%) in the high-risk stratum for major bleedings. Crossing the various strata of the two PARIS risk scores, the largest group of patients consisted of those at high TR and BR (n=130, 22%), followed by those at intermediate risk according to both scores (n=122, 21%). At discharge, TAT was mainly used in patients at intermediate to high BR, while DAT in those at intermediate to high TR but low BR, according to the PARIS score. Conclusion. Our data suggest that some variables associated with increased TR or BR are poorly considered in the daily practice while the use of PARIS scales could help in the implementation of guidelines' recommendations.

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Defining high bleeding risk in patients undergoing percutaneous coronary intervention: a consensus document from the Academic Research Consortium for High Bleeding Risk

European Heart Journal ◽

10.1093/eurheartj/ehz372 ◽

2019 ◽

Vol 40 (31) ◽

pp. 2632-2653 ◽

Cited By ~ 63

Author(s):

Philip Urban ◽

Roxana Mehran ◽

Roisin Colleran ◽

Dominick J Angiolillo ◽

Robert A Byrne ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Clinical Decision Making ◽

Academic Research ◽

Bleeding Risk ◽

Coronary Intervention ◽

Clinical Decision ◽

Consensus Document ◽

Percutaneous Coronary ◽

Research Consortium ◽

High Bleeding Risk

Abstract Identification and management of patients at high bleeding risk undergoing percutaneous coronary intervention are of major importance, but a lack of standardization in defining this population limits trial design, data interpretation, and clinical decision-making. The Academic Research Consortium for High Bleeding Risk (ARC-HBR) is a collaboration among leading research organizations, regulatory authorities, and physician-scientists from the United States, Asia, and Europe focusing on percutaneous coronary intervention–related bleeding. Two meetings of the 31-member consortium were held in Washington, DC, in April 2018 and in Paris, France, in October 2018. These meetings were organized by the Cardiovascular European Research Center on behalf of the ARC-HBR group and included representatives of the US Food and Drug Administration and the Japanese Pharmaceuticals and Medical Devices Agency, as well as observers from the pharmaceutical and medical device industries. A consensus definition of patients at high bleeding risk was developed that was based on review of the available evidence. The definition is intended to provide consistency in defining this population for clinical trials and to complement clinical decision-making and regulatory review. The proposed ARC-HBR consensus document represents the first pragmatic approach to a consistent definition of high bleeding risk in clinical trials evaluating the safety and effectiveness of devices and drug regimens for patients undergoing percutaneous coronary intervention.

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