Antithrombotic Therapy in Patients Taking Oral Anticoagulants and Undergoing Percutaneous Coronary Intervention: Time to Be Bold and Wise.

Abstract

Finding the optimal antithrombotic therapy in patients undergoing percutaneous coronary intervention (PCI) with an indication for long-term oral anticoagulants remains a challenge.1 The ultimate goal is to find the best antithrombotic regimen—the right drugs, at the right doses, for the right duration—to prevent ischemic events while minimizing bleeding. Clinical decision-making requires therefore consideration of ischemic and bleeding risk, whether assessed intuitively or by risk score, taking into account clinical presentation (acute or chronic coronary syndrome), comorbidities (ie, diabetes and renal impairment), coronary anatomy, and other factors.2,3 Patients with atrial fibrillation (AF) treated with coronary stenting account for most of these cases. In this scenario, based on large randomized trials and meta-analyses,4 most recent European guidelines endorse—with the highest class of recommendation—a short course of triple antithrombotic therapy (#1 week) followed by a dual therapy with a nonvitamin K antagonist oral anticoagulant (NOAC) and a P2Y12 inhibitor (preferably clopidogrel).5,6 An alternative regimen consisting of prolonged triple therapy (ie, up to 1 month) is deemed as reasonable in patients at high ischemic and low bleeding risk, but it is based primarily on ‟expert opinion” rather than evidence.5,6 Noteworthy, a non-negligible proportion of patients undergoing PCI receive a combination of anticoagulant and antiplatelet agents for reasons other than AF, such as mechanical valve prostheses, venous thromboembolism, and ventricular thrombosis. In this setting, the evidence is less robust,5,7 and the management remains poorly standardized. Given the difficulty of treating these patients, a nonuniform prescription of antithrombotic regimens persists for both type and duration. Therefore, data from realworld are welcome and useful to understand if and how clinicians integrate novel evidence and follow guidelines recommendations in daily practice. In this issue of the Journal of Cardiovascular Pharmacology, Tanner et al8 presented the results of a real-world retrospective study investigating patients undergoing PCI and having an indication for oral anticoagulation because of various clinical conditions from an Irish high-volume PCI center. Over a 1-year period, 133 of 1650 (or 8.1%) consecutive patients treated with PCI were discharged with a combination of oral antiplatelet and anticoagulant agents,8 which is in line with contemporary cohorts from other European real-world registries.3,9 Most patients had a diagnosis of AF, were discharged on triple antithrombotic therapy, and received a NOAC in preference of vitamin K antagonists as currently advised.5,6 The mean duration of triple therapy was 6 weeks that is—particularly in the case of AF—longer than what guidelines recommend (1-week duration as default strategy), but somewhat justifiable considering that 80% of stent thrombosis in patients with early aspirin discontinuation occurs within the first month after PCI.10