JIM Today 2018 - Saturday - page 6

6
JIM today
Issue 3 
Saturday
 24 February 2018
Taking it all into consideration: antithrombotic
therapy in patients with AF undergoing PCI
T
he management of patients
with atrial fibrillation (AF)
undergoing PCI remains prob-
lematic, with uncertainty on how to
best manage patients requiring both
oral anticoagulation therapy (OAC)
and dual antiplatelet therapy (DAPT).
Speaking to
JIM Today
ahead of the
meeting, Ghada Mikhail (Imperial Col-
lege Healthcare NHS Trust, London,
UK) discussed how clinical decisions
can be made in light of this, with a
look at the latest guidance and data
on the topic.
A recent review by Vidula et al
1
presents the latest understanding
of the balance that must be struck
between ischaemic risk and bleeding
risk, in terms of duration of dual anti-
platelet therapy for patients undergo-
ing PCI. Both ischaemic and bleeding
events increase the risk of mortality,
the authors report, citing a study that
placed cumulative incidence of death
at 0.5% after an ischaemic event
and 0.3% after a bleeding event,
in reported outcomes at 12 and 33
months after PCI
1,2
While stressing that determin-
ing the best course of action for
individual patients requires an assess-
ment of bleeding and ischaemic risk,
the authors note that a changing
landscape of newer generation
stents, coupled with the bleeding
risks associated with long-term DAPT,
mean that shorter-term DAPT has
been addressed in recent studies.
AF patients undergoing PCI present
a further clinical problem, namely
that of determining the duration of
DAPT given that they also need OAC
therapy. In the same work, Vidula et
al review studies investigating alterna-
tives to triple therapy (OAC + P2Y
12
inhibitor + aspirin) that may provide
equal efficacy while reducing relative
bleeding risk.
1
“You need to take a number
of points into consideration,” said
Dr Mikhail, summarising the best
course of action for stented patients
undergoing OAC: “The thrust from all
the studies is that we should be using
direct oral anticoagulants (DOAC)
rather than warfarin. We should be
using low dose rather than full dose
DOACs, and clopidogrel rather than
aspirin combined with anticoagula-
tion therapy.”
Describing the data available to
date, Dr Mikhail cited the WOEST
trial, (What is the Optimal antiplatElet
and anticoagulant therapy in patients
with oral anticoagulation and coro-
nary StenTingtrial, which randomised
patients on OAC undergoing PCI to
either double therapy (clopidogrel +
OAC) or triple therapy (clopidogrel
+ aspirin + OAC). Whilst patients on
double therapy were at lower risk of
bleeding, the study was not powered
to detect differences in thrombot-
ic complications.
3
More re-
cently, DOACs
have been
investigated in
this context.
PIONEER AF was
an open-label,
randomised,
controlled,
multicentre study
exploring two
treatment strategies of rivaroxaban,
and a dose-adjusted oral vitamin K
antagonist treatment strategy in sub-
Clinical crossroads on optimal antithrombotic therapy in patients treated with PCI 
Parini 
Friday 
12:45
Crossroads on optimal antithrombotic therapy in patients treated with PCI 
Parini 
Friday 
12:45
“The thrust from all the
studies is that we should
be using direct oral
anticoagulants (DOAC)
rather than warfarin.”
Ghada Mikhail
On the other hand, a possible competitor is cangre-
lor (which is the topic of the presentation following
mine, by Dominick Angiolillo), which is an intravenous
antiplatelet agent and an ADP blocker. This drug is
probably less powerful as an antithrombotic, but it is
still a very efficacious antiplatelet drug, and prob-
ably with a profile that is maybe a compromise for
some patients.
“My personal point of view is that, in my clinical
practice (at my centre, where we perform a large
number of PCI for acute MI every year) the patients
who can be managed safely only with oral drugs
are the minority. My practice is intending to go on
like this. The support of a parenteral drug, GPIs or
cangrelor, should be used in primary PCI.”
References
1. Puddu PE et al. The role of Glycoprotein IIb/IIIa inhibitors in acute
coronary syndromes and the interference with anemia. Int J Cardiol.
2016;222:1091-6.
2. Safley DM, et al. JACC Cardiol Interv 2015;8:1574-82
3. Iannetta et al. Is There Still a Role for Glycoprotein IIb/IIIa Antago-
nists in Acute Coronary Syndromes? Cardiol Res. 2013;4(1): 1–7.
“My personal point of
view is that, in my clinical
practice … the patients
who can be managed
safely only with oral drugs
are the minority.”
Alberto Menozzi
Continued from page 5
In defense of GPIs in high risk ACS
1,2,3,4,5 7,8,9,10,11,12,13,14,15,16,...20
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