DOI:

Rationale and use of antiplatelet and antithrombotic drugs during cardiovascular interventions

Thomas Cuisset1*, MD; Harald Mudra2, MD; Oliver Muller3, MD PhD; Pierre Vogt3, MD; Anne Angelillo-Scherrer4, MD; Kurt Huber5, MD

Introduction

Recent European Society of Cardiology (ESC) Guidelines have extensively investigated antithrombotic therapy during percutaneous coronary interventions (PCI)1-3. However, based on their complexity and partial difference from existing ACC/AHA guidelines, it is sometimes difficult to follow them in individual decisions. Moreover, most of the recommendations are based on prospective randomised trials, which only partially reflect the “real world” situation. Meta-analyses and guideline-based registries might help to guide daily practice. With respect to cardiovascular interventions the combination of both anticoagulant and antiplatelet therapies is mandatory to prevent thrombosis, because activation of both platelets and the coagulation system contribute to thrombus formation. The choice, initiation and duration of antithrombotic strategies is based on the clinical setting (elective, acute or urgent intervention). To optimise efficacy of therapy and reduce the potential bleeding hazard both, ischaemic and bleeding risks, have to be evaluated on an individual basis. The present report aims to give practical solutions to handle antithrombotic therapy for patients undergoing PCI in various clinical conditions.

Non ST elevation acute coronary syndrome (NSTE-ACS)

See also: Algorithm of NSTE ACS management (Figure 1)

Figure 1. NSTE Acute Coronary Syndrome.

To find the optimal strategy the risk of ischaemic events and the bleeding risk of an individual patient have to be weighed against each other. Thereby, easy to use variables or scores should be preferred.

Assessment of patient risk:

– Higher ischaemic risk:

ST-segment changes, elevated troponin, diabetes, GRACE score >1089

– Higher bleeding risk:

Female, >75 years, bleeding history, GFR<30ml/min, femoral access

Pre-cath management

1. In very high risk patients

(e.g. Persistent Angina, Haemodynamic Instability, Refractory Arrhythmias)

Patients are immediately referred to the cathlab:

UFH 60 IU/kg i.v. bolus, then infusion until PCI with GP IIb/IIIa inhibitors (abciximab)

In patients with high bleeding risk: monotherapy with bivalirudin, 0.1 mg/kg i.v. bolus followed by an infusion of 0.25 mg/kg/hr

2. In medium-to-high risk patients (e.g. troponin-positive, recurrent angina, dynamic ST changes)

Primarily invasive strategy is planned <72h:

In patients <75 years

UFH 60 IU/kg i.v. bolus, then infusion (aPTT-controlled) until PCI

or enoxaparin 1 mg/kg s.c. twice daily until PCI

or fondaparinux 2.5 mg daily s.c. until PCI

In patients > 75 years

UFH 60 IU/kg i.v. bolus, then infusion (aPTT-controlled) until PCI

Fondaparinux 2.5 mg daily s.c.

In case of renal failure (GFR<30 ml/min)

UFH 60 IU/kg i.v. bolus, then infusion (aPTT-controlled) until PCI

3. In low-risk patients

Primarily conservative strategy is planned:

Fondaparinux 2.5 mg s.c. daily

or enoxaparin 1 mg/kg s.c. twice daily

or UFH 60 IU/kg i.v. bolus, then infusion (aPTT-controlled) until PCI

Management in the cathlab

Golden Rule:

Continue the initial therapy! (Don’t switch except after fondaparinux)

If under UFH: Continue perfusion, ACT measurement might be useful

Target range:

- 200-250 sec with GP IIb/IIIa-inhibitors

- 250-350 sec without GP IIb/IIIa-inhibitors

If under enoxaparin:

< 8h of last s.c. application: no additional bolus

within 8-12h of last s.c. application: add 0.30 mg/kg i.v. bolus

>12h of last s.c. application: 0.75 mg/kg i.v. bolus

If under bivalirudin: An additional i.v. bolus of 0.5 mg/kg and an increase of the infusion to 1.75 mg/kg/hour before PCI is performed

If under fondaparinux: UFH 50-100 IU/kg when angiography and PCI is performed

Specific points of interest

Prevention of bleeding

– Assessment of bleeding risk

– No crossover of antithrombotic therapy

– No overdosing of antithrombotic therapy

– Radial access should be the preferred option in high bleeding risk

– Stop anticoagulation after PCI unless a specific indication exists

– Selective downstream use of GP IIb/IIIa-inhibitors in NSTE ACS might be better than unselective upstream use

– A consensual bleeding risk score is highly warranted

Duration of dual antiplatelet therapy

– After bare metal stent (BMS) implantation in stable angina: one month

– After drug eluting stent (DES) implantation (all patients): one year

– After ACS (all patients independent of therapeutic strategy): one year

Golden rules to avoid premature discontinuation of antiplatelet therapy

– Avoid DES in patients not expected to comply with therapy

– Avoid DES if surgery is planned within 12 months

– Detailed information and education of the patient might prevent premature cessation of antiplatelet therapy

– Most surgical procedures can be performed under dual antiplatelet therapy with acceptable rate of bleeding: a multidisciplinary approach is required (cardiologist, anaesthesiologist, surgeon).

In surgical procedures with high bleeding risk:

– Stop clopidogrel five days before surgery and stay on ASA, unless high bleeding risk surgery

– The substitution of combined antiplatelet therapy with LMWH is ineffective and useless

– Restart clopidogrel as soon as possible with loading dose

– In very high risk patients (e.g. multivessel DES<1 years, left main stenting...), in whom cessation of antiplatelet therapy before surgery seems to be dangerous, it has been suggested to switch from clopidogrel five days before surgery to a short half-life antiplatelet agent, e.g. the GP IIb/IIIa-inhibitors tirofiban or eptifibatide and stop infusion of these agents four hours before surgery.

Patient under chronic anticoagulation

To avoid long-term triple antithrombotic therapy, BMS implantation or the use of pure balloon dilatation is preferred over the use of DES.

Antiplatelet therapy monitoring

– No consensual test system available

– No consensual definition of “non”– or “low” – response

– No large clinical evidence that tailored antiplatelet therapy improves clinical outcomes

– Monitoring of antiplatelet response by platelet function assays is used at present only in clinical research. Data are not strong enough to support the common use of the available assay systems in daily clinical practice.

Patients with aspirin hypersensitivity

If aspirin is highly required a “rapid desensitisation procedure” should be performed17

Heparin induced thrombocytopenia (HIT)

In patient with a history of HIT, neither UFH nor LMWH should not be used (cross reactivity). Bivalirudin is the best option in this case for elective PCI and ACS. Others options are argatroban, lepirudin and danaparoid.

Volume 4 Number 2
Aug 20, 2008
Volume 4 Number 2
View full issue


Key metrics

Suggested by Cory

Editorial

10.4244/EIJ-E-24-00065 Apr 21, 2025
From invasive gradients to pressure recovery: rethinking long-standing paradigms
Joner M and Mylotte D
free

Editorial

10.4244/EIJ-E-25-00011 Apr 21, 2025
Transcatheter aortic valve implantation with complex, high-risk indicated PCI
Patterson T and McDonaugh B
free

Flashlight

10.4244/EIJ-D-24-00871 Apr 21, 2025
Management of bioprosthetic valve failure at 10 years after TAV-in-SAV
Jelisejevas J et al

Debate

10.4244/EIJ-E-24-00071 Apr 21, 2025
Could the age threshold for TAVI be relaxed to below 65 years? Pros and cons
Garot P et al

State-of-the-Art

10.4244/EIJ-D-24-00066 Apr 21, 2025
Management of complications after valvular interventions
Bansal A et al
free
Trending articles
69.746

10.4244/EIJV13I12A217 Dec 8, 2017
Swimming against the tide: insights from the ORBITA trial
Al-Lamee R and Francis D
free
58.8

State-of-the-Art

10.4244/EIJ-D-24-00066 Apr 21, 2025
Management of complications after valvular interventions
Bansal A et al
free
57.6

State-of-the-Art

10.4244/EIJ-D-24-00386 Feb 3, 2025
Mechanical circulatory support for complex, high-risk percutaneous coronary intervention
Ferro E et al
free
39.45

Clinical research

10.4244/EIJ-D-23-00725 Nov 19, 2023
A systematic algorithm for large-bore arterial access closure after TAVI: the TAVI-MultiCLOSE study
Rosseel L et al
free
39.45

Original Research

10.4244/EIJ-D-23-00725 Mar 18, 2024
A systematic algorithm for large-bore arterial access closure after TAVI: the TAVI-MultiCLOSE study
Rosseel L et al
free
38.75

State-of-the-Art

10.4244/EIJ-D-23-00912 Oct 7, 2024
Optical coherence tomography to guide percutaneous coronary intervention
Almajid F et al
free
36

State-of-the-Art

10.4244/EIJ-D-23-00448 Jan 15, 2024
Coronary spasm and vasomotor dysfunction as a cause of MINOCA
Yaker ZS et al
free
28.5

CLINICAL RESEARCH

10.4244/EIJV11I1A6 May 19, 2015
European expert consensus on rotational atherectomy
Barbato E et al
free
X

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

EuroPCR EAPCI
PCR ESC
Impact factor: 7.6
2023 Journal Citation Reports®
Science Edition (Clarivate Analytics, 2024)
Online ISSN 1969-6213 - Print ISSN 1774-024X
© 2005-2025 Europa Group - All rights reserved