Rotational Thromboelastometry in High-Risk Patients on Dual Antithrombotic Therapy After Percutaneous Coronary Intervention

Abstract

Aims: Patients using antithrombotic drugs after percutaneous coronary intervention (PCI) are at risk for bleeding and recurrent ischemia. We aimed to explore routine and tissue plasminogen activated (tPA) ROTEM results in a post-PCI population on dual antithrombotic treatment.Methods and Results: In this prospective cohort, 440 patients treated with double antithrombotic therapy after recent PCI and with ≥3 risk factors for either ischemic or bleeding complications were included and compared with a control group (n = 95) consisting of perioperative patients not using antithrombotic medication. Laboratory assessment, including (tPA) ROTEM, was performed one month post-PCI and bleeding/ischemic complications were collected over a five-month follow-up. Patients were stratified by antithrombotic regimen consisting of a P2Y12 inhibitor with either aspirin (dual antiplatelet therapy; DAPT, n = 323), a vitamin K antagonist (VKA, n = 69) or a direct oral anticoagulant (DOAC, n = 48). All post-PCI patients had elevated ROTEM clot stiffness values, but only the DAPT group additionally presented with a decreased fibrinolytic potential as measured with tPA ROTEM. Patients receiving anticoagulants had prolonged clotting times (CT) when compared to the control and DAPT group; EXTEM and FIBTEM CT could best discriminate between patients (not) using anticoagulants (AUC > 0.97). Furthermore, EXTEM CT was significantly prolonged in DAPT patients with bleeding complications during follow-up (68 [62–70] vs. 62 [57–68], p = 0.030).Conclusion: ROTEM CT has high potential for identifying anticoagulants and tPA ROTEM could detect a diminished fibrinolytic potential in patients using DAPT. Furthermore, the ability of EXTEM CT to identify patients at risk for bleeding may be promising and warrants further research.

Blood Coagulation and Beyond: Position Paper from the Fourth Maastricht Consensus Conference on Thrombosis

“…In an effort to include as many components of the haemostatic system as possible, more robust and global assays were developed such as thrombin generation assays, viscoelastic assays (thromboelastography/-metry) and microfluidic models (178); (175,179). Some of the global assays, like thrombin generation and thromboelastometry, have demonstrated potential to improve the identification of patients on antithrombotic drugs who are at risk of bleeding (180,181). Still, clinical applicability of these global assays is difficult due to (pre-)analytical variables, duration of test procedure and interpretation of test results.…”

“… 199 202 203 Some of the global assays, like thrombin generation and thromboelastometry, have demonstrated potential to improve the identification of patients on antithrombotic drugs who are at risk of bleeding. 204 205 Still, clinical applicability of these global assays is difficult due to (pre-)analytical variables, duration of test procedure, and interpretation of test results.…”