Heparin Bridging vs. Uninterrupted Oral Anticoagulation in Patients With Atrial Fibrillation Undergoing Coronary Artery Stenting

Lahtela, Heli; Rubboli, Andrea; Schlitt, Axel; Karjalainen, Pasi P.; Niemelä, Matti; Vikman, Saila; Puurunen, Marja; Weber, Michael; Valencia, José; Biancari, Fausto; Lip, Gregory Y.H.; Airaksinen, Juhani

doi:10.1253/circj.cj-11-1206

Cited by 38 publications

(13 citation statements)

References 22 publications

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“…In the multicenter Atrial Fibrillation undergoing Coronary Artery Stenting (AFCAS) registry, uninterrupted anticoagulation was shown to be similar to conventional bridging therapy with heparin, after adjustment for propensity score, in terms of both major adverse cardiac and cerebrovascular events (1.16; 95% CI, 0.44-3.05; P=0.76) and bleeding complications (1.38; 95% CI, 0.77-2.48; P=0.28). 94 However, whether continuation of OAC is a safe option in the peri-PCI period remains unproven without confirmation from a dedicated randomized clinical trial.…”

Section: Intraprocedural Anticoagulationmentioning

confidence: 99%

Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

Capodanno

Angiolillo

2014

Circ: Cardiovascular Interventions

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A trial fibrillation (AF), the most common cardiac arrhythmia, occurs in 1% to 2% of the general population, with a prevalence varying from 0.5% in subjects 40 to 50 years old to 5% to 15% in the elderly who are >80 years old. [1][2][3] Stroke is the most feared complication of AF, resulting in death or disabling symptoms in a vast proportion of cases. 4 In the Framingham study, the age-adjusted incidence of stroke was 5-fold higher in subjects with AF, and the attributable risk raised from 1.5% at 50 to 59 years to 23.5% at 80 to 89 years. 5Chronic oral anticoagulation (OAC) therapy is the mainstay of stroke prevention in patients with AF at high risk for cardioembolic sequelae; ≈70% to 80% of all patients with AF have an indication for OAC, and coronary artery disease coexists in 20% to 30% of them. 6,7 With an estimated prevalence of AF in 1% to 2% of the population, it may be projected that ≈1 to 2 million patients on OAC in both the United States and Europe are candidates for coronary revascularization, often in the form of percutaneous coronary interventions (PCI). Patients undergoing PCI, as well as those who present with an acute coronary syndrome (ACS), also require dual antiplatelet therapy (DAPT), usually aspirin in combination with a platelet adenosine diphosphate P2Y 12 receptor antagonist, with the goal of reducing the risk of ischemic recurrences, including stent thrombosis. 8 However, the efficacy and safety of combining OAC with DAPT (triple antithrombotic therapy) in these patients is a topic of debate. In fact, although this combination can potentially prevent both thromboembolism and atherothrombotic events, it is also associated with an increased risk of severe bleeding. In a large nationwide registry of 40 812 patients hospitalized with myocardial infarction (MI), the risk of subsequent hospitalizations for bleeding increased with the number of antithrombotic drugs used, being 1.8-fold in patients on vitamin K antagonists (VKAs) and aspirin, 3.5-fold in patients on VKAs and clopidogrel, and 4-fold in patients on triple therapy, with numbers needed to harm of 45.4, 15.2, and 12.5, respectively. 9 On this background, treatment with OAC and antiplatelet agents requires careful consideration of the risks and benefits associated with each drug and their combination.On one hand, the challenge of balancing the risk of thromboembolism (ie, stroke) and atherothrombotic events (ie, stent thrombosis) and, on the other, the risk of bleeding demand for a timely review of the literature on using various combinations of OAC and antiplatelet therapies in patients with coexisting AF and coronary artery disease. This is also underscored by the recent availability of newer antithrombotic agents, including oral anticoagulants (ie, dabigatran, rivaroxaban, apixaban) and antiplatelets (ie, prasugrel, ticagrelor). This article reviews the evidence supporting antithrombotic agents for AF and ACS/PCI, and describes contemporary antithrombotic regimens and practical recommendations for patients with both condition...

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Section: Intraprocedural Anticoagulationmentioning

confidence: 99%

Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

Capodanno

Angiolillo

2014

Circ: Cardiovascular Interventions

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“…11 The AFCAS (Atrial Fibrillation undergoing Coronary Artery Stenting) registry is a prospective multicenter registry that enrolled patients with AF referred for PCI and stenting between December 2006 and February 2010. 12- 15 In this prespecified analysis, we performed an analysis of data from the prospective AFCAS registry to explore the 12-month clinical outcomes of patients with AF undergoing PCI with DES vs. BMS implantation.…”

Section: Baseline Clinical and Procedural Characteristicsmentioning

confidence: 99%

Bare-Metal vs. Drug-Eluting Stents in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Kiviniemi

Puurunen

Schlitt

et al. 2014

Circ J

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“…However, existing scores such as CHA 2 DS 2 -VASC and HAS-BLED have not been validated in case of anticoagulation interruption or potential bridging therapy. In the prospective multicenter AFCAS (Atrial Fibrillation undergoing Coronary Artery Stenting) registry, bleeding complications and major adverse cardiac and cerebrovascular events (MACCE) including death, myocardial infarction (MI), target vessel revascularization, stent thrombosis and stroke have been assessed during a 30-day follow-up period in 290 patients treated with uninterrupted OAC with VKA and in 161 patients with bridging therapy (BT) conducted for a median of 3 days before coronary artery stenting [11]. The international normalized ratio (INR) before PCI was higher (2.3 vs. 1.8, p < 0.001) and radial access was more common (43% vs. 14%, p < 0.001) in the uninterrupted OAC group.…”

Section: Peri-procedural Antithrombotic Managementmentioning

confidence: 99%

Antithrombotic management in patients with percutaneous coronary intervention requiring oral anticoagulation

Zalewski¹,

Undas²

2016

pwki

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The dynamic evolution of therapeutic options including the use of vitamin K antagonists (VKA), non-vitamin K oral anticoagulants (NOAC), more potent antiplatelet drugs as well as new generation drug-eluting stents could lead to the view that the current recommendations on the management of patients with percutaneous coronary intervention (PCI) requiring oral anticoagulation do not keep up with the results of several clinical studies published within the last 5 years. In the present overview, we summarize the recent advances in antithrombotic management used in atrial fibrillation patients undergoing PCI for stable coronary artery disease or acute coronary syndrome (ACS). The safety and efficacy of prasugrel and ticagrelor taken with oral anticoagulants also remain to be established in randomized trials; therefore the P2Y12 inhibitor clopidogrel on top of aspirin or without is now recommended to be used together with a VKA or NOAC. It is still unclear which dose of a NOAC in combination with antiplatelet agents and different stents should be used in this clinical setting and whether indeed NOAC are safer compared with VKA in such cardiovascular patients. Moreover, we discuss the use of anticoagulation in addition to antiplatelet therapy for secondary prevention in patients with ACS. To minimize bleeding risk in anticoagulated patients following PCI or ACS, the right agent should be prescribed to the right patient at the right dose and supported by regular clinical evaluation and laboratory testing, especially assessment of renal function when a NOAC is used.

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Heparin Bridging vs. Uninterrupted Oral Anticoagulation in Patients With Atrial Fibrillation Undergoing Coronary Artery Stenting

Cited by 38 publications

References 22 publications

Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

Bare-Metal vs. Drug-Eluting Stents in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Antithrombotic management in patients with percutaneous coronary intervention requiring oral anticoagulation

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