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Uninterrupted oral anticoagulation versus bridging in patients with long-term oral anticoagulation during percutaneous coronary intervention: subgroup analysis from the WOEST trial

Selected in EuroIntervention by S. Brugaletta

References

Authors

Dewilde WJ, Janssen PW, Kelder JC, Verheugt FW, De Smet BJ, Adriaenssens T, Vrolix M, Brueren GB, Van Mieghem C, Cornelis K, Vos J, Breet NJ, Ten Berg JM

Published

2015 August

Link

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My Comment

What is known 

Approximately 20-30% of patients with atrial fibrillation (AF) or mechanical heart valves who need oral anticoagulation (OAC) have concomitant ischaemic heart disease, which may require percutaneous coronary intervention (PCI) with stenting. The optimal periprocedural anticoagulation treatment during PCI is unclear. There are two options: the first is to continue therapeutic OAC throughout the periprocedural period (UAC), and the second is to discontinue OAC prior to PCI (BT). Whereas the first may increase thrombo-embolic risk, the latter require patient hospitalization in some cases. This sub-analysis tests the hypothesis that periprocedural UAC does not increase bleeding or thrombotic or thromboembolic complications in patients receiving OAC undergoing PCI in the WOEST trial. 

Major findings 

  • Bleeding complications and MACCE were assessed in patients treated according to UAC (n=241) and BT (n=322) regimen.
  • After 30 days, as well as after one year, there were no significant differences in bleeding complications (HR 1.14, 95% CI: 0.77-1.69, p=0.51, and HR 1.26, 95% CI: 0.94-1.69, p=0.12, respectively) and MACCE.
  • MACCE tended to be less frequent in the UAC group (respectively HR 0.48, 95% CI: 0.15-1.51, p=0.21, and HR 0.72, 95% CI: 0.46-1.14, p=0.16).
  • Additionally, adjustment with a propensity score revealed no significant differences.
  • Peri-procedural INR was not associated with bleeding or MACCE.

My comment

Patients under vitamin-K treatment who need coronary angiography and PCI need special attention with regards on what to do with anticoagulant treatment. Although some studies, including this one, seem to favor the UAC regimen, in clinical practice both approaches are used, according to operators’ preferences. This is because guidelines in this topic are quite confusing. This particular study reinforces the message that UAC regimen is a safe option in these patients. Some points are important to discuss. Firstly, many patients received femoral approach and not all of them received a closure devices; it is unclear if bleeding complications were found to be more frequent in this group. A second point of discussion is which antithrombotic regimen should be used in those patients with an UAC regimen either in terms of which drug or in terms of which dose. 

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