Coronary artery disease
Long-Term Outcomes in Patients Undergoing Coronary Stenting on Dual Oral Antiplatelet Treatment Requiring Oral Anticoagulant Therapy

https://doi.org/10.1016/j.amjcard.2008.08.021Get rights and content

In patients undergoing coronary stenting, long-term dual antiplatelet therapy with aspirin and clopidogrel reduces atherothrombotic events but also increases the risk of bleeding. The potential for developing bleeding complications is further enhanced in patients also requiring oral anticoagulant treatment (“triple therapy”). The aim of the study is to assess long-term outcomes associated with the use of triple-therapy in patients undergoing coronary stenting and evaluate how these may be affected by targeting international normalized ratio (INR) values to the lower therapeutic range. We prospectively studied 102 consecutive patients undergoing coronary stenting treated with dual antiplatelet therapy also requiring oral anticoagulation. INR was targeted to the lower therapeutic range (2.0 to 2.5). Patients requiring oral anticoagulant therapy because of mechanical valve prosthesis were excluded. Patients were followed for 18 months, and bleeding, defined according to Thrombolysis in Myocardial Infarction criteria, and major adverse cardiac events were recorded. Outcomes were compared with a control group (n = 102) treated only with dual antiplatelet therapy. The mean duration of triple therapy was 157 ± 134 days. At 18 months, a nonsignificant increase in bleeding was observed in the triple versus dual therapy group (10.8% vs 4.9%, p = 0.1). INR values were higher in patients with bleeding (2.8 ± 1.1 vs 2.3 ± 0.2, p = 0.0001). In patients who had INR values within the recommended target (79.4%), the risk of bleeding was significantly lower compared with patients who did not (4.9 vs 33%, p = 0.00019) and with that observed in the control group (4.9%). An INR >2.6 was the only independent predictor of bleeding. There were no significant differences in major adverse cardiac events between groups (5.8% vs 4.9%, p = 0.7). In conclusion, in patients undergoing coronary stenting on triple therapy, targeting lower therapeutic INR values reduces the risk of bleeding complications.

Section snippets

Methods

All consecutive patients undergoing coronary stent implantation treated with aspirin (100 mg/day) and clopidogrel (75 mg/day) and who also required oral anticoagulant therapy were prospectively evaluated at 3 institutions. Between October 2005 and August 2006, a total of 1,678 consecutive patients underwent stent implantation. Of these, 118 (7%) required concomitant oral anticoagulant therapy. Patients with mechanical valve prosthesis (n = 16) were excluded. In patients meeting study

Results

A total of 102 study patients were available for the present analysis; 64 patients were discharged on triple therapy, and 34 of these were already on oral anticoagulation for >1 month at the time of hospitalization. Oral anticoagulation was suspended in patients already on oral anticoagulation, except for those presenting with ST-elevation myocardial infarction (n = 11), and PCI was performed when an INR value <1.5 was reached. In the remaining 38 patients, the need for oral anticoagulant

Discussion

The optimal antithrombotic therapy in patients undergoing coronary stenting in whom dual antiplatelet therapy is required but who also have an indication for oral anticoagulation represents a common clinical problem that clinicians frequently face. The fine balance between safety and efficacy in this cohort needs careful consideration. In fact, discontinuation of antiplatelet therapy increases the risk of stent thrombosis, and even temporary withholding of anticoagulant increases the risk of

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    2018, International Journal of Cardiology
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    To date, no dedicated studies have been carried out in VTE patients on OAC undergoing PCI. When included in experiences evaluating the use and outcome of antithrombotic therapies in patients with a general indication for OAC who were submitted to PCI, the proportion of VTE patients was small, ranging from approximately 2 to 17% (10% on average), as opposed to 22 to 85% (61% on average) for AF, and, most importantly, outcome data were not given separately (Table 1) [3–33]. Also, the absolute incidence of (recurrent) VTE during follow-up was as little as less than 1%, whereas that of stroke was in the range of 0 to 9% (1.5% on average) (Table 1) [3–33].

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