Author: Rubboli, Andrea

Source: Vascular Disease Prevention, Volume 3, Number 2, May 2006 , pp. 153-158(6)

Publisher: Bentham Science Publishers

Abstract:

Dual antiplatelet treatment with aspirin and a thienopyridine (either ticlopidine or clopidogrel) is currently recommended after percutaneous coronary intervention with stent implantation (PCI-S). This regimen has been proven superior to the combination of oral anticoagulation (OAC) and aspirin, which at present, has therefore little role in this setting. In patients undergoing PCI-S with an indication for long-term OAC, because of atrial fibrillation, mechanical heart valve, previous thromboembolism, etc., the optimal antithrombotic treatment is currently unknown. The limited available evidence shows substantial variability in the management of these patients, who are treated according to standardized protocols only in 54% of cases. The adopted strategies include, either selected or systematic, substitution of OAC for dual antiplatelet therapy in 25 to 54% of cases, addition to OAC of a single antiplatelet agent in 12 to 25% and institution of triple therapy with OAC, aspirin and a thienopyridine in about 60%. OAC is systematically aimed at a lower intensity in 33% of cases only, whereas in another 29% this is pursued when a high hemorrhagic risk is perceived. In 69% of patients having exchanged OAC for dual antiplatelet administration, the original treatment is resumed after 1 to 3-6 months, with longterm association of an antiplatelet agent in most cases. Both efficacy and safety of the various antithrombotic regimens were suboptimal in the small series reported, with a 30-day occurrence of thrombotic and major bleeding complications of 4% and 3 to 7%, respectively. For current practice, stratification of medium-term risk of thrombo-embolism upon OAC interruption is warranted. In low-risk patients (i.e. lone atrial fibrillation, venous thromboembolism > 6 months, etc.), preprocedural OAC interruption and substitution for dual antiplatelet treatment, to be continued for the following 1 to 6 months, is appropriate. In medium- to high-risk patients (i.e. mitral or multiple mechanical valves, recent arterial or venous thromboembolism, etc.), medium-term triple therapy with OAC, aspirin and a thienopyridine should be adopted. In both risk groups, drug-eluting stents should be avoided as much as possible, due to the prolonged need for dual antiplatelet treatment. In the absence of strongly supportive evidence however, large scale registries and clinical trials are warranted to confirm the currently suggested strategies and to evaluate alternative antithrombotic regimens in patients with and indication for OAC undergoing PCI-S, whose number is likely to progressively increase over the next years.

Keywords: Coronary angioplasty; coronary stent; oral anticoagulants; antiplatelets

Document Type: Research article

DOI: http://dx.doi.org/10.2174/156727006776819459

Affiliations: 1: Cardiac Catheterization Laboratory, Division of Cardiology, Maggiore Hospital, Largo Nigrisoli 2, I-40133 Bologna, Italy.

Publication date: 2006-05-01

More about this publication?

• Vascular Disease Prevention publishes reviews as well as original papers to update all those concerned with this topic at the clinical or scientific level. In addition to clinically relevant topics, we consider reviews and original papers dealing with the more scientific aspects of vascular disease prevention. This includes the evaluation of emerging vascular risk factors, research dealing with the pathogenesis of atherosclerosis and the investigation of new treatment options both at the clinical and scientific level (e.g. epidemiology, patient-based studies, experimental models, in vitro experiments or molecular research). Therefore, another function of Vascular Disease Prevention is to bridge the gap between clinical practice and ongoing laboratory-based research.
  
  In particular, we welcome critical reviews and comments on recent trials. This is a topic that requires regular updates because of the large number of trials published every year.
  
  Debates are encouraged in the correspondence section of this journal.
  The editorial structure of Vascular Disease Prevention is set up with the aim of dealing with the submitted material as rapidly as possible. Specialist editors will provide a more expert and rapid assessment unlike a more centralized editorial structure.

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