Early In-hospital Discontinuation of Aspirin on the First Post-procedural Day After Percutaneous Coronary Stent Implantation in Patients on Direct Oral Anticoagulation

Overview

Journal Front Cardiovasc Med

Specialty Cardiology & Vascular Diseases

Date 2023 Dec 29

PMID 38155989

Authors

Philipp von Stein

Lukas Seitz

Hendrik Wienemann

Christopher Hohmann

Till Baar

Stephan Baldus

Marcel Halbach

Affiliations

Soon will be listed here.

Abstract

Background: Previous trials investigating antithrombotic therapy with a direct oral anticoagulant (DOAC) and a P2Y12 inhibitor after percutaneous coronary intervention (PCI), termed dual therapy, allowed a short period of triple therapy including a DOAC, a P2Y12 inhibitor, and aspirin.

Aims: This study aimed to determine whether discontinuation of aspirin on the first post-procedural day is safe or causes ischemic events.

Methods: Ischemic and bleeding events during hospitalization were investigated retrospectively in all patients treated with dual therapy (DOAC + P2Y inhibitor, designated as group 1) or triple therapy (DOAC + P2Y inhibitor+aspirin, designated as group 2) from day 1 after PCI at our center.

Results: Of 4,564 consecutive PCI procedures, 1,059 (23.2%) had an indication for OAC. Of these, 322 met the inclusion criteria for group 1 and 62 for group 2. Baseline characteristics, CHADS-VASc and HAS-BLED scores showed no relevant differences between the two groups, and the main indication for DOAC therapy was atrial fibrillation in both groups. Approximately ¼ of patients were treated for acute coronary syndrome. The mean length of post-procedural hospitalization was 2.1 ± 2.5 and 2.2 ± 3.0 days in group 1 and 2, respectively ( = 0.305). One patient per group suffered a TIA ( = 0.297). There were no other ischemic events and no statistically significant differences in bleeding events. A subgroup analysis of cases hospitalized for ≥2 post-procedural days (group 1: 100 cases, mean 4.4 ± 3.4 days vs. group 2: 25 cases, mean 4.0 ± 4.1 days) confirmed these results.

Conclusion: The initiation of dual therapy and thus discontinuation of aspirin on the first postprocedural day appears to be safe with respect to short-term ischemic events in a real-world population. Almost ¼ of patients undergoing PCI have an indication for OAC, highlighting the relevance of this issue.

References

van Rein N, Heide-Jorgensen U, Lijfering W, Dekkers O, Sorensen H, Cannegieter S . Major Bleeding Rates in Atrial Fibrillation Patients on Single, Dual, or Triple Antithrombotic Therapy. Circulation. 2018; 139(6):775-786. DOI: 10.1161/CIRCULATIONAHA.118.036248. View

Capodanno D, Angiolillo D . Management of antiplatelet and anticoagulant therapy in patients with atrial fibrillation in the setting of acute coronary syndromes or percutaneous coronary interventions. Circ Cardiovasc Interv. 2014; 7(1):113-24. DOI: 10.1161/CIRCINTERVENTIONS.113.001150. View

Gibson C, Mehran R, Bode C, Halperin J, Verheugt F, Wildgoose P . Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med. 2016; 375(25):2423-2434. DOI: 10.1056/NEJMoa1611594. View

Pisters R, Lane D, Nieuwlaat R, de Vos C, Crijns H, Lip G . A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010; 138(5):1093-100. DOI: 10.1378/chest.10-0134. View

Vranckx P, Valgimigli M, Eckardt L, Tijssen J, Lewalter T, Gargiulo G . Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet. 2019; 394(10206):1335-1343. DOI: 10.1016/S0140-6736(19)31872-0. View

Chesebro J, Knatterud G, Roberts R, Borer J, Cohen L, Dalen J . Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987; 76(1):142-54. DOI: 10.1161/01.cir.76.1.142. View

Kuramitsu S, Ohya M, Shinozaki T, Otake H, Horie K, Kawamoto H . Risk Factors and Long-Term Clinical Outcomes of Second-Generation Drug-Eluting Stent Thrombosis. Circ Cardiovasc Interv. 2019; 12(6):e007822. DOI: 10.1161/CIRCINTERVENTIONS.119.007822. View

Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C . 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2019; 41(3):407-477. DOI: 10.1093/eurheartj/ehz425. View

Lip G, Nieuwlaat R, Pisters R, Lane D, Crijns H . Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2009; 137(2):263-72. DOI: 10.1378/chest.09-1584. View

10.

Mehran R, Rao S, Bhatt D, Gibson C, Caixeta A, Eikelboom J . Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011; 123(23):2736-47. DOI: 10.1161/CIRCULATIONAHA.110.009449. View

11.

Lopes R, Heizer G, Aronson R, Vora A, Massaro T, Mehran R . Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation. N Engl J Med. 2019; 380(16):1509-1524. DOI: 10.1056/NEJMoa1817083. View

12.

Urban P, Mehran R, Colleran R, Angiolillo D, Byrne R, Capodanno D . Defining High Bleeding Risk in Patients Undergoing Percutaneous Coronary Intervention. Circulation. 2019; 140(3):240-261. PMC: 6636810. DOI: 10.1161/CIRCULATIONAHA.119.040167. View

13.

Capodanno D, Huber K, Mehran R, Lip G, Faxon D, Granger C . Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI: JACC State-of-the-Art Review. J Am Coll Cardiol. 2019; 74(1):83-99. DOI: 10.1016/j.jacc.2019.05.016. View

14.

Michniewicz E, Mlodawska E, Lopatowska P, Tomaszuk-Kazberuk A, Malyszko J . Patients with atrial fibrillation and coronary artery disease - Double trouble. Adv Med Sci. 2017; 63(1):30-35. DOI: 10.1016/j.advms.2017.06.005. View

15.

Angiolillo D, Bhatt D, Cannon C, Eikelboom J, Gibson C, Goodman S . Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention: A North American Perspective: 2021 Update. Circulation. 2021; 143(6):583-596. DOI: 10.1161/CIRCULATIONAHA.120.050438. View

16.

. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993; 329(10):673-82. DOI: 10.1056/NEJM199309023291001. View

17.

Hindricks G, Potpara T, Dagres N, Arbelo E, Bax J, Blomstrom-Lundqvist C . 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the.... Eur Heart J. 2020; 42(5):373-498. DOI: 10.1093/eurheartj/ehaa612. View

18.

Gori T, Polimeni A, Indolfi C, Raber L, Adriaenssens T, Munzel T . Predictors of stent thrombosis and their implications for clinical practice. Nat Rev Cardiol. 2018; 16(4):243-256. DOI: 10.1038/s41569-018-0118-5. View

19.

Collet J, Thiele H, Barbato E, Barthelemy O, Bauersachs J, Bhatt D . 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020; 42(14):1289-1367. DOI: 10.1093/eurheartj/ehaa575. View

20.

Dewilde W, Oirbans T, Verheugt F, Kelder J, de Smet B, Herrman J . 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. DOI: 10.1016/S0140-6736(12)62177-1. View