Are glycoprotein inhibitors safe during percutaneous coronary intervention in patients on chronic warfarin treatment?

Summary

The aim of this study was to evaluate the safety of glycoprotein IIb/IIIa inhibitors (GPIs) during percutaneous coronary intervention (PCI) in patients on chronic warfarin therapy due to atrial fibrillation (AF).We analysed all consecutive AF patients (N = 377, mean age 70 years, male 71%) on warfarin therapy referred for PCI in seven centres. Major bleeding, access site complications and major adverse cardiovascular events were recorded during hospitalisation. A total of 111 patients (29%) received periprocedural GPIs with a wide inter-hospital variation in their use (range 3–68%).The use of GPIs increased with the severity of the disease presentation and 49% of patients with ST-elevation myocardial infarction received GPIs. Mean periprocedural international normalised ratio (INR) of patients who received GPIs was 1.89 (range 1.1–3.3). Major bleeding was more common in the patients treated with GPIs (9.0% vs. 1.5%, p = 0.001) than in those without GPIs, but there was no difference in major adverse cardiovascular events between the groups. In multivariable analysis, use of GPIs (odds ratio [OR]???????????5.1, 95% confidence interval [CI]???????????1.3–20.6, p = 0.02) and old age (OR 1.2, 95% CI 1.0–1.3, p = 0.02) remained as the only independent predictors of major bleeding. Also after adjusting for propensity score, GPIs remained as a significant predictor of major bleeding (OR 3.8, 95% CI 1.03–14.1, p = 0.045). In the GPI group, major bleeding was not predicted by INR level or warfarin pause. GPIs increase the risk of major bleeding events irrespective of periprocedural INR levels and should be used with caution in this fragile patient group.

Keywords

Antithrombotic treatment - angioplasty - anticoagulation - bleeding complications

• References

• 1 Helft G, Gilard M, Le Feuvre C. et al. Drug insight: antithrombotic therapy after percutaneous coronary intervention in patients with an indication for anticoagulation. Nat Clin Pract Cardiovasc Med 2006; 03: 673-680.
• 2 Wang T, Robinson L, Ou F. et al. Discharge antithrombotic strategies among patients with acute coronary syndrome previously on warfarin anticoagulation: physician practice in the CRUSADE registry. Am Heart J 2008; 155: 361-368.
• 3 Rubboli A, Halperin J, Airaksinen K. et al. Antithrombotic therapy in patients treated with oral anticoagulation undergoing coronary artery stenting. An expert consensus document with focus on atrial fibrillation. Ann Med 2008; 40: 428-436.
• 4 Antman E, Hand M, Armstrong P. et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 2008; 117: 296-329.
• 5 Anderson J, Adams C, Antman E. et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007; 116: e148-304.
• 6 Annala A, Karjalainen P, Porela P. et al. Safety of diagnostic coronary angiography during uninterrupted therapeutic warfarin treatment. Am J Cardiol 2008; 102: 386-390.
• 7 Karjalainen P, Porela P, Ylitalo A. et al. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J 2007; 28: 726-732.
• 8 Karjalainen P, Vikman S, Niemelä M. et al. Safety of percutaneous coronary intervention during uninterrupted oral anticoagulant treatment. Eur Heart J 2008; 29: 1001-1010.
• 9 Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. N Engl J Med 1998; 338: 1488-1497.
• 10 Cutlip D, Windecker S, Mehran R. et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 2007; 115: 2344-2351.
• 11 Sourgounis A, Lipiecki J, Lo T. et al. Coronary stents and chronic anticoagulation. Circulation 2009; 119: 1682-1688.
• 12 Fuster V, Rydén L, Cannom D. et al. ACC/AHA/ ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Eur Heart J 2006; 27: 1979-2030.
• 13 Bonow R, Carabello B, Kanu C. et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114: e84-231.
• 14 Douketis J, Berger P, Dunn A. et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (Suppl. 06) 299S-339S.
• 15 Vikman S, Airaksinen K, Tierala I. et al. Gender-related differences in the management of non-ST-elevation acute coronary syndrome patients. Scand Cardiovasc J 2007; 41: 287-293.
• 16 Boersma E, Harrington R, Moliterno D. et al. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet 2002; 359: 189-198.
• 17 Manzano-Fernández S, Pastor F, Marín F. et al. Increased major bleeding complications related to triple antithrombotic therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting. Chest 2008; 134: 559-567.
• 18 Alexander K, Chen A, Newby L. et al. Sex differences in major bleeding with glycoprotein IIb/IIIa inhibitors: results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/ AHA guidelines) initiative. Circulation 2006; 114: 1380-1387.
• 19 Lopes R, Pieper K, Horton J. et al. Short-and long-term outcomes following atrial fibrillation in patients with acute coronary syndromes with or without ST-segment elevation. Heart 2008; 94: 867-873.
• 20 Moscucci M, Fox K, Cannon C. et al. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2003; 24: 1815-1823.