Antiplatelets After PCI in Patients Needing Anticoagulation
Evaluation of: Dewilde WJ, Oirbans T, Verheugt FW et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomized, controlled trial. Lancet 381(9872), 1107–1115 (2013). Long-term oral anticoagulant (OAC) and dual-antiplatelet therapy are commonly needed in patients with atrial fibrillation and in patients undergoing percutaneous coronary intervention (PCI), respectively. The combination of atrial fibrilation and PCI is frequent, and leads to a dilemma for antithrombotic therapy, where risk of stroke or stent thrombosis must be balanced with bleeding risk. In the WOEST study, 573 patients on OAC undergoing PCI were randomly assigned to receive clopidogrel alone or clopidogrel plus aspirin. The primary end point was the occurrence of any bleeding episode during 1-year follow-up. Clopidogrel alone administered to patients taking OAC after PCI was associated with a significantly lower rate of bleeding complications than clopidogrel plus aspirin. Moreover, a composite secondary end point of death, myocardial infarction and stent thrombosis was significantly lower in the dual-therapy group compared with the triple-therapy group. In spite of its limitations, the WOEST study constitutes a major breakthrough, showing that long-term aspirin after PCI may be obsolete in certain circumstances. This needs to be confirmed in further studies.
This paper reviews the recent article by Dewilde et al., demonstrating that clopidogrel alone administered to patients taking oral anticoagulants (OACs) who require percutaneous coronary intervention (PCI) is associated with a significantly lower rate of bleeding complications at 1 year than clopidogrel plus aspirin. Long-term OAC is needed in patients with mechanical heart valves or with atrial fibrillation (AF), and a high CHA2DS2-VASc score. Dual-antiplatelet therapy with aspirin and a P2Y12 inhibitor (clopidogrel, or recently, prasugrel and ticagrelor in acute coronary syndrome) represents the recommended therapy in patients undergoing PCI in order to prevent stent thrombosis. Unfortunately, combination of AF and PCI is common in approximately 5% of AF patients, leading to a dilemma where risk of stroke or stent thrombosis must be balanced with bleeding risk before choosing antithrombotic therapy. Currently, European guidelines for OAC after PCI are based on limited data and need to be improved, while newer, more updated guidelines for the management of AF patients are now available. Bernard et al. recently found that OAC use was a factor independently associated with a lower risk of death, stroke and systemic embolism in AF patients needing stent implantation. However, triple therapy (OAC, aspirin and clopidogrel) at the initial phase has been associated with high bleeding rates, and physicians may be reluctant to use this strategy. Moreover, a new generation of drug-eluting stents, new antiplatelet agents and new OACs have entered the market, adding complexity and uncertainty. The WOEST study is the first trial in which the aim was to simplify the antithrombotic management in these patients by removing aspirin from the antiplatelet therapy strategy.
Abstract and Introduction
Abstract
Evaluation of: Dewilde WJ, Oirbans T, Verheugt FW et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomized, controlled trial. Lancet 381(9872), 1107–1115 (2013). Long-term oral anticoagulant (OAC) and dual-antiplatelet therapy are commonly needed in patients with atrial fibrillation and in patients undergoing percutaneous coronary intervention (PCI), respectively. The combination of atrial fibrilation and PCI is frequent, and leads to a dilemma for antithrombotic therapy, where risk of stroke or stent thrombosis must be balanced with bleeding risk. In the WOEST study, 573 patients on OAC undergoing PCI were randomly assigned to receive clopidogrel alone or clopidogrel plus aspirin. The primary end point was the occurrence of any bleeding episode during 1-year follow-up. Clopidogrel alone administered to patients taking OAC after PCI was associated with a significantly lower rate of bleeding complications than clopidogrel plus aspirin. Moreover, a composite secondary end point of death, myocardial infarction and stent thrombosis was significantly lower in the dual-therapy group compared with the triple-therapy group. In spite of its limitations, the WOEST study constitutes a major breakthrough, showing that long-term aspirin after PCI may be obsolete in certain circumstances. This needs to be confirmed in further studies.
Introduction
This paper reviews the recent article by Dewilde et al., demonstrating that clopidogrel alone administered to patients taking oral anticoagulants (OACs) who require percutaneous coronary intervention (PCI) is associated with a significantly lower rate of bleeding complications at 1 year than clopidogrel plus aspirin. Long-term OAC is needed in patients with mechanical heart valves or with atrial fibrillation (AF), and a high CHA2DS2-VASc score. Dual-antiplatelet therapy with aspirin and a P2Y12 inhibitor (clopidogrel, or recently, prasugrel and ticagrelor in acute coronary syndrome) represents the recommended therapy in patients undergoing PCI in order to prevent stent thrombosis. Unfortunately, combination of AF and PCI is common in approximately 5% of AF patients, leading to a dilemma where risk of stroke or stent thrombosis must be balanced with bleeding risk before choosing antithrombotic therapy. Currently, European guidelines for OAC after PCI are based on limited data and need to be improved, while newer, more updated guidelines for the management of AF patients are now available. Bernard et al. recently found that OAC use was a factor independently associated with a lower risk of death, stroke and systemic embolism in AF patients needing stent implantation. However, triple therapy (OAC, aspirin and clopidogrel) at the initial phase has been associated with high bleeding rates, and physicians may be reluctant to use this strategy. Moreover, a new generation of drug-eluting stents, new antiplatelet agents and new OACs have entered the market, adding complexity and uncertainty. The WOEST study is the first trial in which the aim was to simplify the antithrombotic management in these patients by removing aspirin from the antiplatelet therapy strategy.
Source...