Are glycoprotein inhibitors safe during percutaneous coronary intervention in patients on chronic warfarin treatment?

Abstract

The aim of this study was to evaluate the safety of glycoprotein IIb/IIIa inhibitors (GPIs) during percutaneous coronary intervention (PCI) in patients on chronic warfarin therapy due to atrial fibrillation (AF). We analysed all consecutive AF patients (N = 377, mean age 70 years, male 71%) on warfarin therapy referred for PCI in seven centres. Major bleeding, access site complications and major adverse cardiovascular events were recorded during hospitalisation. A total of 111 patients (29%) received periprocedural GPIs with a wide inter-hospital variation in their use (range 3-68%). The use of GPIs increased with the severity of the disease presentation and 49% of patients with ST-elevation myocardial infarction received GPIs. Mean periprocedural international normalised ratio (INR) of patients who received GPIs was 1.89 (range 1.1-3.3). Major bleeding was more common in the patients treated with GPIs (9.0% vs. 1.5%, p = 0.001) than in those without GPIs, but there was no difference in major adverse cardiovascular events between the groups. In multivariable analysis, use of GPIs (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.3-20.6, p = 0.02) and old age (OR 1.2, 95% CI 1.0-1.3, p= 0.02) remained as the only independent predictors of major bleeding. Also after adjusting for propensity score, GPIs remained as a significant predictor of major bleeding (OR 3.8, 95% CI 1.03-14.1, p = 0.045). In the GPI group, major bleeding was not predicted by INR level or warfarin pause. GPIs increase the risk of major bleeding events irrespective of periprocedural INR levels and should be used with caution in this fragile patient group.

The management of patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation

“…However, a 2.5% rate of major bleedings should be anticipated and subtracted from postdischarge incidence when evaluating the long‐term safety of antithrombotic regimens. In accordance with earlier reports, use of glycoprotein IIb/IIIa antagonists and acute coronary syndrome, where aggressive antithrombotic regimens are commonly warranted, were significantly associated with major bleeding complications . Again, the importance of the vascular approach, as well as of elevated INR levels, was confirmed, although statistical significance was reached only for minor bleeding.…”

“…Also, the true efficacy and safety profile of the various postdischarge antithrombotic regimens, namely triple therapy (TT) of vitamin K‐antagonist (VKA), aspirin and clopidogrel, is incompletely defined, owing to the general lack of information about the drug combination actually ongoing at the time of an adverse event . Finally, the separate contribution to the overall bleeding rate of the in‐hospital hemorrhagic events, which may be related more to periprocedural variables, such as the vascular access site, the adoption of bridging anticoagulation strategies, and the use of glycoprotein IIb/IIIa inhibitors , has seldom been reported .…”

The risk of bleeding of triple therapy with vitamin K-antagonists, aspirin and clopidogrel after coronary stent implantation: Facts and questions

“…Such figure is not substantially different from that reported in the overall population of patients undergoing PCI-S,[39] therefore supporting the concept that TT in itself does not substantially impact on the incidence of early major bleeding. Further reduction of the in-hospital major bleeding rate may probably be obtained by more extensively using the radial approach, which has been shown to virtually eliminate the occurrence of bleeding at the vascular access site,[40] and by further limiting the use of glycoprotein IIb/IIIa inhibitors, as well as of heparin bridging strategies following the (likely unnecessary) peri-procedural withdrawal of VKA, which both have been found associated with early hemorrhagic complications [41],[42]…”

The Management of Patients on Oral Anticoagulation Undergoing Coronary Stent Implantation: A Survey among Interventional Cardiologists from Eight European Countries

“…While unfractionated heparin is the preferred intraprocedural antithrombotic agent, current uncertainty about the value of INR warranting additional anticoagulation and the dose of heparin to be given at the beginning of PCI‐S is reflected by the about 50% split response rate. On the other hand, the recommended restrictions on the administration of glycoprotein IIb/IIIa inhibitors in OAC patients, in whom the risk of major bleeding is increased 4 to 5‐fold, 9 appear clearly acknowledged. The 600 mg loading dose of clopidogrel, which is preferred over the traditional dose of 300 mg, appears to be a reasonable option in OAC patients.…”