New findings from the SWEDEHEART registry suggest that uninterrupted oral anticoagulant (OAC) therapy should be the preferred strategy in patients on these medicines undergoing percutaneous coronary intervention (PCI).
Similar peri-procedural cardiovascular and bleeding risks were observed compared to patients whose treatment was interrupted for unplanned PCI in the acute setting; however, those who remained on OAC treatment throughout saw shorter hospital stays.
The new analysis of 6,485 patients in the Swedish registry was published online Monday and appears in the April 12 issue of JACC: Cardiovascular Interventions. The authors, led by Dimitrios Venetsanos, MD, PhD, of the Karolinska Institutet and Karolinska University Hospital, Stockholm, reported links with a range of pharmaceutical companies including OAC-makers Boehringer Ingelheim, Pfizer and Bayer.
They noted that around 10% of patients referred for PCI are on long-term OAC treatment, usually because of atrial fibrillation (AF), venous thromboembolism or a mechanical prosthetic heart valve.
This number is only set to rise as the population ages and prevalence of AF grows, they said.
Nevertheless, there remains a lack of data over the optimal peri-procedural management of OAC treated patients.
The researchers, therefore, ran an analysis of the SWEDEHEART registry, which includes all patients admitted to the hospital for a suspected acute coronary syndrome (ACS) and all patients undergoing coronary catheterization in Sweden, with 100% coverage for the latter.
All patients on OAC who were admitted acutely and underwent PCI or coronary angiography with a diagnostic procedure from 2005 through 2007 were included – totaling 3,322 patients whose OAC was interrupted and 3,163 uninterrupted OAC patients in the final analysis.
Outcomes were major adverse cardiac and cerebrovascular events (MACCE; death, myocardial infarction or stroke) and bleeds at 120 days.
The cumulative incidence of MACCE was 8.2% (269 events) in the interrupted group vs. 8.2% (254 events) for uninterrupted patients. Adjusting with propensity score for the nonrandomized treatment selection, the risk of MACCE did not differ between the groups (hazard ratio [HR]: 0.89; 95% confidence interval [CI]: 0.71 to 1.12).
Neither was any difference found in the risk of MACCE or bleeds, with 12.6% for interrupted OAC and 12.9% for uninterrupted (adjusted HR: 0.87; 95% CI: 0.70 to 1.07).
The risk of major or minor in-hospital bleeds also did not differ between the two groups.
However, shorter hospital stay was seen for those on uninterrupted OAC therapy, “probably making U-OAC more cost effective,” the researchers said.
Hospital stays were a median of 4 days (interquartile range [IQR]: 3 to 7) for those on uninterrupted OACs vs. 5 days (IQR: 3 to 8 days) for the interrupted patients (p < 0.01).
The results support current European Society of Cardiology guidelines, which recommend uninterrupted OAC therapy as the preferred peri-procedural antithrombotic strategy, the researchers added.
However, they stressed that the need for additional anticoagulation therapy during procedures for patients undergoing coronary angiography and PCI with uninterrupted OAC treatment remains unclear, as does optimal timing for P2Y12 receptor inhibitor administration.
Shades of gray
In an accompanying editorial, Piera Capranzano, MD, PhD, from the University of Catania, Italy, and Dominick J. Angiolillo, MD, PHD, from the University of Florida College of Medicine, said the similarities among results for interrupted and uninterrupted OAC treatment suggest “either of these approaches can be an option in clinical practice.”
They added, “Multiple factors, including the bleeding and thrombotic risk profiles of the individual patient, clinical indication of the procedure, or logistical needs may influence the decision to choose one strategy over the other.”
For example, the uninterrupted approach may be considered for those at high thrombotic risk.
They went on to call for further studies with granular data collection to adequately answer which is the optimal antithrombotic management strategy for patients on long-term OAC medication who need coronary invasive procedures.
Venetsanos D, Skibniewski M, Janzon M, et al. Uninterrupted Oral Anticoagulant Therapy in Patients Undergoing Unplanned Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2021;14:754–63.
Capranzano P, Angiolillo DJ. Evidence and Recommendations for Uninterrupted Versus Interrupted Oral Anticoagulation in Patients Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2021;14:764-7.