Antithrombotic treatment for patients on oral anticoagulation undergoing coronary stenting: a review of the available evidence and practical suggestions for the clinician

Abstract

Background: Dual antiplatelet treatment with aspirin and a thienopyridine is the antithrombotic treatment recommended after coronary stenting. Such strategy is generally not applicable in most patients with an indication for oral anticoagulation (OAC), for whom however, information about the optimal antithrombotic regimen is currently limited.

Methods: In order to derive some practical indications for the clinicians who are requested to care for these patients, the available evidence on the use, safety and efficacy of the various antithrombotic strategies was reviewed.

Results: A substantial variability in the choice of treatment was observed in current practice where, however, standardized management protocols are seldom used. Triple therapy with OAC, aspirin and a thienopyridine is the most frequently adopted regimen, although its safety appears suboptimal, due to an apparent increased incidence of major hemorrhagic complications. Conversely, the efficacy of the combination of OAC and aspirin is suboptimal, so that such regimen should be considered only for patients at very high hemorrhagic risk, and in association with the implantation of more "biocompatible" stents.

Conclusions: While waiting for further studies to generate more consistent evidence, the choice of the antithrombotic treatment for patients with an indication for OAC undergoing coronary stenting should be guided by careful stratification of both thrombotic/thromboembolic and hemorrhagic risks. In general, however, the implantation of drug-eluting stents should be avoided, due to the prolonged need for dual antiplatelet administration, and the radial approach preferred, due to the virtual elimination of bleeding complications at the arterial access site.