Oral Anticoagulation Use Common in PCI Patients, With Triple Therapy the Norm at Discharge

Roughly one out of every 11 patients undergoing PCI is on chronic oral anticoagulation, setting up a situation in which triple therapy—including aspirin and a P2Y12 inhibitor—will be used in a large proportion, a new analysis shows. In addition to having a higher risk of in-hospital bleeding, patients on anticoagulation are more likely to require readmission within 90 days and have worse long-term survival.

The study, published online October 17, 2016, in the Journal of the American Heart Association, “demonstrates that these patients have underlying characteristics that put them at risk for long-term morbidity and mortality,” lead author Eric Secemsky, MD (Massachusetts General Hospital, Boston), told TCTMD. “We need to really make sure that we use all our efforts to work on reducing the occurrence of these adverse events both in the short- and long-term periods.”

What specific actions might be taken to lower risks in anticoagulated patients is not entirely clear, senior author Robert Yeh, MD (Beth Israel Deaconess Medical Center, Boston), added. Trying to perform all procedures transradially may work for reducing short-term risks of bleeding, he said, but further research is needed to determine what is actually leading to adverse events in this population.

Commenting on the study for TCTMD, John Messenger, MD (University of Colorado Hospital, Aurora), said it is “a call to action for this group of people, because there’s significant harm associated with oral anticoagulation [in terms of] long-term outcomes after PCI.”

At the moment, clinicians rely on individualized assessments of bleeding and ischemic risks to determine the best way to move forward, Messenger said. But, he added, “the reality is that lots of patients are on these medications currently and we don’t really know the best treatment algorithm for minimizing risk after hospital discharge.”

Outcomes Suffer in Anticoagulated Patients

What to do with anticoagulated patients when they come to the cardiac cath lab is a common consideration for interventional cardiologists, Yeh said, who noted that there have been only a few studies—mostly conducted before introduction of the non-vitamin K antagonist oral anticoagulants (NOACs)—investigating what proportion of patients undergoing PCI are taking oral anticoagulation.

To explore the issue, Yeh, Secemsky, and colleagues looked at data on 9,566 patients who underwent PCI between June 2009 and September 2014 in the Partners HealthCare system. Overall 8.8% were on oral anticoagulation in the 30 days leading up to the procedure, mostly for atrial fibrillation or flutter. That rate remained stable over time, but the proportion of anticoagulated patients taking a NOAC increased from 0% in 2009 to 17.6% in 2014. The vast majority (84.9%) were discharged on triple therapy.

In fully adjusted models, patients who were on anticoagulation had greater risks of the following outcomes:

• In-hospital major bleeding (OR 1.50; 95% CI 1.14-1.99)
• Access-site bleeding (OR 1.82; 95% CI 1.07-3.09)
• Non-access-site bleeding (OR 1.69; 95% CI 1.27-2.26)
• 90-day readmission (OR 1.40; 95% CI 1.16-1.69)
• Long-term mortality (HR 1.36; 95% CI 1.11-1.66)

There were no differences between anticoagulated patients taking a NOAC and those taking a vitamin K antagonist, although the authors note that the study was underpowered for those comparisons.

WOEST Impact?

The high rate of triple therapy seen at discharge, which did not change during the study period, seems to show that the WOEST trial results did not have an impact on practice, the investigators note. That study, presented in August 2012, showed that eliminating aspirin and treating patients with only clopidogrel and an oral anticoagulant lessened bleeding and lowered the rate of a composite of stroke, death, MI, stent thrombosis, and TVR.

When asked why WOEST didn’t have an impact, Messenger pointed out that the trial was relatively small and didn’t get included in the guidelines in a strong fashion. Thus, clinicians continued treating patients the way they did before the trial results were released, he said.

Secemsky pointed out that there is generally little information in the guidelines to address the best way to manage anticoagulated patients who are undergoing PCI. He noted that there are multiple trials underway and said guidance will likely be revisited once results become available. Both PIONEER AF-PCI and REDUAL-PCI are evaluating this question.