Maintaining oral anticoagulation (OAC) throughout an unplanned cardiac catheterization confers no extra risk and might hold some advantages over periprocedural OAC interruption in patients on long-term anticoagulation therapy, suggests a major registry analysis.
There was no significant difference in adjusted risk of bleeding or in a primary endpoint that included death and ischemic events whether OAC was uninterrupted and interrupted (U-OAC and I-OAC, respectively).
The study involved only patients on OAC for atrial fibrillation or other indications who were sent to cardiac cath for suspected non-ST-segment-elevation acute coronary syndrome (ACS), primarily, and possible percutaneous coronary intervention (PCI).
Of 6485 patients in this study, all participants in the SWEDEHEART registry who underwent their coronary procedures from 2005 to 2017, about 84% were on warfarin, but about 16% were taking direct oral anticoagulants (DOACs), which had become available only in the latter years.
There was no interaction between the OAC agent used and the safety or effectiveness of either periprocedural strategy, notes a report on the study published in the April 12 issue of the JACC: Cardiovascular Interventions.
U-OAC, compared with I-OAC, was associated with a moderately shorter hospitalization time, “probably making U-OAC more cost-effective,” speculate the authors, led by Dimitrios Venetsanos, MD, PhD, Karolinska Institutet and Karolinska University Hospital, Stockholm.
The findings, they write, support recent consensus recommendations from the European Society of Cardiology (ESC) and other non-North American organizations “advocating U-OAC as the preferred periprocedural antithrombotic strategy.”
In contrast, observes an accompanying editorial, consensus-based recommendations from North American groups reserve the U-OAC approach “only for very urgent or emergency procedures” and favor I-OAC for nonemergent procedures.
The current study “is to date the largest to investigate the efficacy and safety of uninterrupted compared with interrupted OAC before unplanned PCI,” a clinical issue with few randomized-trial data for guidance, write Piera Capranzano, MD, PhD, Policlinico Hospital, University of Catania, Italy, and Dominick J. Angiolillo, MD, PhD, University of Florida College of Medicine, Jacksonville.
The study is only observational, and even its several multivariate analyses can’t account for all possible confounders, such as the specifics of parenteral anticoagulation used during procedures. But it “provides the best available data assessing differences between uninterrupted and interrupted OAC in unplanned PCI,” they write, and is the first of its kind to include patients treated with DOACs.
“It does move the needle forward in terms of data, and provides support for the European document. But it’s not convincing enough to change my practice,” Angiolillo told theheart.org | Medscape Cardiology. Still, “in specific cases, when you have to move forward with a procedure and the patient hasn’t interrupted the oral anticoagulant, now there are some data suggesting that it’s okay to proceed.”
That decision could be influenced by the patient’s bleeding and thrombotic risk profiles or other factors, the editorial notes, but such concerns are less an issue with the burgeoning preference for DOACs over vitamin K antagonists.
The effects of DOACs, “which have become the standard of care, are more rapid in onset and offset,” Angiolillo said. “This allows you to proceed with the procedure using the parenteral anticoagulation you need without concerns of over-anticoagulating the patient.”
Therefore, in practice, “stopping the DOAC the day before is really not that big of a deal. You’re not exposing the patient to any increased risk of a thrombotic event.”
Of the 3163 in the U-OAC group and 3322 in the I-OAC group, about 80% presented with some form of ACS and many others with signs of acute decompensated heart failure. After propensity matching based on 40 variables, there were 2108 patients in each group.
Clinical outcomes at 120 days were not significantly different between the U-OAC and I-OAC groups in several multivariate analyses that arrived at hazard ratios by different methods.
| Outcomes at 120 Days, I-OAC vs U-OAC, in SWEDEHEART
||Hazard Ratio (95% CI)*
|MACCE, primary endpoint
|MACCE or bleeding
|Death from any cause
|MACCE = major adverse cardiac and cerebrovascular events (including death, myocardial infarction, and stroke)
*by the stabilized inverse probability of treatment weights method
Median hospital stay was shorter with U-OAC than with I-OAC (4 vs 5 days; P < .01). Although use of DOACs over time had increased to about 53% of patients by 2017, the difference in hospitalization time “remained significant after adjustment for calendar year,” the group writes.
“At the end of the day, you need to proceed with what’s best for the patient,” Angiolillo said. “The evidence for uninterrupted oral anticoagulation isn’t strong, but it does suggest that in selected cases, you may want to consider it. But I don’t believe that these are data that can guide us toward routine use of an uninterrupted strategy.”
Venetsanos has received a grant from Boston Scientific; disclosures for the other authors are in the report. Angiolillo discloses receiving consulting fees or honoraria from Abbott, Amgen, Aralez, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, PhaseBio, PLx Pharma, Pfizer, Sanofi, and The Medicines Company; and payments for participation in review activities from CeloNova and St. Jude Medical. Capranzano discloses no relevant relationships.
J Am Coll Cardiol Intv. 2021;14:754-763, 764-767. Abstract, Editorial
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