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Combination therapy with anticoagulants and antiplatelets during percutaneous coronary intervention reduces incidence of stent thrombosis.
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The role of monitoring during percutaneous coronary intervention is variable depending on the type of antithrombotic used.
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Clinical benefit of tailored antiplatelet therapy based on point-of-care tests has yet to be proved.
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Reversal agents (if available) for the various antithrombotics may be necessary when major bleeding occurs or emergent surgery is needed.
Monitoring and Reversal of Anticoagulation and Antiplatelets
Section snippets
Key points
Anticoagulants
Predisposition to thrombosis during catheterization exists because of exposure of clotting factors to disrupted endothelium, catheters, and guidewires. The goals of anticoagulation therapy are to minimize thrombus propagation on the endovascular surface and formation of new thrombi from PCI equipment use.5, 12 Ideal anticoagulation would effectively prevent thrombus formation, have low risk of bleeding, have safe monitoring profile, have short duration of effect (half-life), and could be
Antiplatelets
Platelets are a key player in thrombotic events. Once the integrity of normal endothelium has been compromised, platelet adhesion, activation, and aggregation lead to formation of thrombus. Adhesion of platelets to the site of vessel wall injury occurs via von Willebrand factor and other GP cell receptors (GP Ib/IX/V, GP IV, GP VI, GP Ia/IIa). Once platelets start adhering, they become activated, initiating further activation of surrounding platelets through the secretion of platelet granules
Summary
Anticoagulation and antiplatelet therapy have been heavily studied since their inception. Although certain agents have advantages and disadvantages relative to others, there will likely never be a 1 size fits all medication. The art of practicing medicine requires tailoring therapy based on the unique patient being treated. This statement holds true during PCI as well, in which certain presentations or preexisting comorbidities make 1 anticoagulant or antiplatelet agent better than another. It
References (146)
- et al.
Comparison of neointimal coverage by optical coherence tomography of a sirolimus-eluting stent versus a bare-metal stent three months after implantation
Am J Cardiol
(2008) - et al.
Antithrombotic therapy in patients undergoing coronary angioplasty
Chest
(1998) Transluminal dilatation of coronary-artery stenosis
Lancet
(1978)- et al.
Effectiveness of low-dose heparin in prevention of myocardial reinfarction
Lancet
(1987) - et al.
Low-molecular-weight heparin versus unfractionated heparin in acute ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention with drug-eluting stents
Am Heart J
(2010) - et al.
Effects of various anticoagulant treatments on von Willebrand factor release in unstable angina
J Am Coll Cardiol
(2000) - et al.
Heparin and low-molecular-weight heparin: mechanisms of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and safety
Chest
(1998) - et al.
The relationship of anticoagulation level and complications after successful percutaneous transluminal coronary angioplasty
Am Heart J
(1992) - et al.
Relation between procedural activated coagulation time and outcome after percutaneous transluminal coronary angioplasty
J Am Coll Cardiol
(1994) - et al.
2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions
J Am Coll Cardiol
(2011)
Effects of differing rates of protamine reversal of heparin anticoagulation
Surgery
Parenteral anticoagulants: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
Pharmacology of low molecular weight heparins
Emerg Med Clin North Am
Combining enoxaparin and glycoprotein IIb/IIIa antagonists for the treatment of acute coronary syndromes: final results of the National Investigators Collaborating on Enoxaparin-3 (NICE-3) study
Am Heart J
Low molecular weight heparin versus regular heparin or aspirin in the treatment of unstable angina and silent ischemia
J Am Coll Cardiol
The Thrombolysis in Myocardial Infarction B Trial Investigators. TIMI 11B. Enoxaparin versus unfractionated heparin for unstable angina or non-Q-wave myocardial infarction: a double-blind, placebo-controlled, parallel-group, multicenter trial. Rationale, study design, and methods
Am Heart J
Adding intravenous unfractionated heparin to standard enoxaparin causes excessive anticoagulation not detected by activated clotting time: results of the STACK-on to ENOXaparin (STACKENOX) study
Am Heart J
Safety of concomitant therapy with eptifibatide and enoxaparin in patients undergoing percutaneous coronary intervention: results of the coronary revascularization using integrilin and single bolus enoxaparin study
J Am Coll Cardiol
Are activated clotting times helpful in the management of anticoagulation with subcutaneous low-molecular-weight heparin?
Am Heart J
In vitro comparison of the effect of heparin, enoxaparin and fondaparinux on tests of coagulation
Thromb Res
Monitoring of low-molecular-weight heparins in cardiovascular disease
Am J Cardiol
A unique, low dose of intravenous enoxaparin in elective percutaneous coronary intervention
J Am Coll Cardiol
Applications of monitoring platelet glycoprotein IIb/IIIa antagonism and low molecular weight heparins in cardiovascular medicine
Am Heart J
A novel point-of-care enoxaparin monitor for use during percutaneous coronary intervention. Results of the Evaluating Enoxaparin Clotting Times (ELECT) Study
J Am Coll Cardiol
Antithrombotic therapy during percutaneous coronary intervention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest
Protamine reversal of anticoagulation achieved with a low molecular weight heparin. The effects on eicosanoids, clotting and complement factors
Thromb Res
Bleeding risk and reversal strategies for old and new anticoagulants and antiplatelet agents
J Thromb Haemost
A dose-finding study of fondaparinux in patients with non-ST-segment elevation acute coronary syndromes: the Pentasaccharide in Unstable Angina (PENTUA) Study
J Am Coll Cardiol
Bivalirudin versus heparin during coronary angioplasty for unstable or postinfarction angina: final report reanalysis of the Bivalirudin Angioplasty Study
Am Heart J
Argatroban for elective percutaneous coronary intervention: the ARG-E04 multi-center study
Int J Cardiol
The primary and secondary prevention of coronary artery disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition)
Chest
Combining antiplatelet and anticoagulant therapies
J Am Coll Cardiol
Stent thrombogenicity early in high-risk interventional settings is driven by stent design and deployment and protected by polymer-drug coatings/clinical perspective
Circulation
Stent endothelialization
Circulation
ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions
Circulation
Percutaneous transluminal dilatation of chronic coronary stenoses. First experiences
Schweiz Med Wochenschr
A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease
N Engl J Med
A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease
N Engl J Med
Adjunctive pharmacotherapy for coronary stenting
Curr Opin Cardiol
Predictors of bleeding and time dependence of association of bleeding with mortality/clinical perspective
Circulation
Anticoagulant therapy for percutaneous coronary intervention
Circ Cardiovasc Interv
Anticoagulation in percutaneous coronary intervention
Intervent Cardiol
Anti-platelet and anti-thrombotic approaches in patients undergoing percutaneous coronary intervention
Catheter Cardiovasc Interv
Guide to anticoagulant therapy: heparin: a statement for healthcare professionals from the American Heart Association
Circulation
Combination antithrombotic therapy in unstable rest angina and non-Q-wave infarction in nonprior aspirin users: primary end points analysis from the ATACS Trial. Antithrombotic Therapy in Acute Coronary Syndromes Research Group
Circulation
Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina: a meta-analysis
JAMA
Acute coronary artery occlusion during and after percutaneous transluminal coronary angioplasty: frequency, prediction, clinical course, management, and follow-up
Circulation
Heparin binding to plasma proteins, an important mechanism for heparin resistance
Thromb Haemost
Factor-Xa inactivation by antithrombin. 3. Evidence for biological stabilization of factor Xa by factor V-phospholipid complex
Br J Haematol
Platelet activation with unfractionated heparin at therapeutic concentrations and comparisons with a low-molecular-weight heparin and with a direct thrombin inhibitor
Circulation
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Disclosure: The authors have nothing to disclose.