• Identify Risks & Maximize Benefits Before, During & After PCI

    January 21, 2015

    By: Henry S. Jennings, III, MD, FSCAI, and Joaquin E. Cigarroa, MD, FSCAI

    Interventional cardiologists and patients with both atrial fibrillation and an indication for percutaneous coronary intervention (PCI) share a common dilemma: the balance between an improvement in quality of life obtained from PCI including stents versus the risks of bleeding, stent thrombosis and risk of thromboemboli related to atrial fibrillation and the selection of anticoagulation and antiplatelet medications.

    It is important to perform shared decision making to identify the risk and benefits to the patients. We recommend the following steps to help mitigate the risks and maximize the benefits to a patient:


    Pre-procedural Guidance

    1. Estimate the risk of stroke utilizing the CHA2DS2-VASC risk score1 to determine whether the patient benefits from the use of an oral anticoagulant. A score of 0 is considered low-risk and does not require anticoagulation. A patient with a score of 1 is low-moderate risk and should be considered for antiplatelet therapy or anticoagulation, with antiplatelet therapy most commonly selected. A score of >1 is moderate-high risk and systemic anticoagulation should be considered.

    2. Estimate the risk of bleeding utilizing the HAS-BLED risk score2. While a HAS-BLED score of greater than or equal to 3 should be considered high-risk for bleeding, the HAS-BLED score per se should not be used to exclude patients from anticoagulation. Rather, it should be the basis for shared decision making discussions.


    Peri-procedural Guidance

    1. Preload patients on dual antiplatelet therapy and statins in an effort to decrease the need for  glycoprotein 2b/3a inhibitors.

    2. Select a radial approach over a femoral approach to decrease the risk of vascular complications, which are increased via the femoral approach when anticoagulants are resumed post procedure.

    3. Select appropriate dosing of antithrombotic therapies (unfractionated heparin or bivalirudin) and avoid the use of low molecular weight heparinm as minor bleeding is increased.

    4. When appropriate, choose a bare metal stent (BMS) over a drug eluting stent (DES) unless the risk of restenosis is substantially increased.


    Post-Procedure Management

    1. Avoid bridging, when feasible.

    2. Treat patients who are deemed not at a high risk of bleeding with triple therapy, including aspirin 81 mg daily, clopidogrel 75 mg daily, and warfarin with INR goal of 2 to 2.5.

    3. Patients at a high risk of bleeding may be considered for the use of warfarin with clopidogrel (no aspirin), based on the WOEST study3. Patients on dual therapy, as opposed to triple therapy have a reduction in serious bleeding (12.7% to 6.5%), as defined by Bleeding Academic Research Consortium, and a reduction in blood transfusions ( 9.5% to 3.9%).

    4. Utilize proton pump inhibitors to minimize the risk of upper gastrointestinal bleeding.

    5. Educate patients to avoid all nonsteroidals and to select acetaminophen for analgesia.

    6. Novel anticoagulants should not be combined with the use of aspirin and clopidogrel, as the risk of bleeding is increased relative to triple therapy with warfarin.

    7. When using triple therapy, discontinue clopidogrel 4 to 6 weeks post BMS and 3 to 6 months post second generation DES4.


    References

    1. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014.

    2. Lip GY, Frison L, Halperin JL, et al. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score. J Am Coll Cardiol. 2011;57(2):173-80.

    3. Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013;381(9872):1107-15.

    4. Feres, F, Costa RA, Abizaid A, et al. Three vs twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial. JAMA. 2013;310(23):2510-22.