An expert panel appointed by the American College of Cardiology (ACC) has published in the Journal of the American College of Cardiology a consensus decision pathway for anticoagulant and antiplatelet use in patients with atherosclerotic cardiovascular disease (CVD) or in those with atrial fibrillation (AF) or venous thromboembolism (VTE) undergoing percutaneous coronary intervention (PCI).
In the statement, panel members describe 4 clinical scenarios summarized below and involving AF or VTE.
Patients With AF on Anticoagulants Who Now Need PCI
The panel recommends lifelong treatment with oral anticoagulants (OACs) in patients with AF who are appropriate candidates for this therapy. Direct OACs (DOACs) should be continued in patients taking these medications prior to PCI, but clinicians should consider adding P2Y12 inhibitors (P2Y12I).
A general principle for the management of these patients is to take into account their ischemic and bleeding risk when developing an antithrombotic regimen. In addition, DOACs are preferred after PCI in patients with AF due to the therapy’s simplicity, rapid onset of action, low risk for major and fatal intracranial bleeding, and lack of need for bridging anticoagulation.
In addition, clinicians should consider continuing a vitamin K antagonist after PCI in patients with AF who had good international normalized ratio (INR) control prior to intervention. Clinicians could also consider continuing 81 mg/day aspirin following intervention until the INR reaches the therapeutic range.
The panel emphasizes that care should be taken in evaluating a chosen P2Y12I, given the intensity and duration of the agent. Due to the higher risk for bleeding with prasugrel and ticagrelor, the panel recommends preferring clopidogrel after PCI in patients indicated for long-term OAC. Ticagrelor may also be considered in these patients.
Patients on Antiplatelet Therapy (APT) With a New Diagnosis of AF
A general principle for the management of patients on APT with a new diagnosis of AF is to first assess their thromboembolic and bleeding risks. The panel notes that the CHA2DS2-VASc score represents “the most extensively validated and widely used tool” clinicians can use to assess a patient’s risk for stroke or systemic embolism. Patients with scores lower than the ones indicated in the ACC/American Heart Association/Heart Rhythm Society guidelines (CHA2DS2-VASc score: men, ≥2; women, ≥3) may be considered for treatment with OACs, based on additional clinical factors and patient preferences. The risks and benefits associated with the use of OACs should also be discussed in patients on APT with a new AF diagnosis.
Patients in this setting who have an indication for OAC and an acceptable bleeding risk should undergo reassessment of the original and current indication(s) for APT. Medical history and a physical examination should be conducted during this assessment. Clinicians should also look for signs of CVD, including angina and recent neurological symptoms. The panel also provides several recommendations for the management of antithrombotic therapy based on indication for APT, including for patients at risk for or with: atherosclerotic CVD (ASCVD), stable ischemic heart disease (SIHD), acute coronary syndrome (ACS), cerebrovascular disease, and peripheral artery disease (PAD).
Patient With Prior VTE Being Considered for PCI
The panel recommends a time-limited course of OAC after VTE provoked by a transient nonsurgical risk factor, or surgery in patients with prior VTE who are being considered for PCI.
Indefinite anticoagulant therapy is recommended in patients who have an average risk for bleeding, and time-limited therapy should be considered in patients at increased risk for bleeding. Clinicians should reassess the risks and benefits of continuing anticoagulant therapy on an annual basis in patients on indefinite treatment.
PCI should be deferred in patients requiring the procedure within the first 3 months of a time-limited OAC course for VTE. Deferral should last until the OAC therapy regimen is completed. Additional recommendations are provided regarding combination anticoagulant/APT therapy, particularly in terms of reducing bleeding risk.
Patients on APT With New VTE
In these patients, clinicians may wish to consider 75 to 100 mg aspirin daily for the primary prevention of ASCVD, especially for patients ages 40 to 70 years at high risk for ASCVD but not for bleeding. Also, patients on single APT for SIHD without a history of ACS and no prior revascularization should stop any APT and initiate an anticoagulant regimen.
Application of the Consensus Statement
“This is a complex topic, and we have attempted to cite the literature to offer direct guidance when possible and to highlight areas in which clinical judgment is needed,” noted the expert panel. ”We hope this document will aid in the management of this common yet challenging subset of patients.”
Writing Committee, Kumbhani DJ, Cannon CP, et al. 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease: A report of the American College of Cardiology Solution Set Oversight Committee . Published online November 26, 2020. J Am Coll Cardiol. doi:10.1016/j.jacc.2020.09.011