Rotational Thromboelastometry in High-Risk Patients on Dual Antithrombotic Therapy After Percutaneous Coronary Intervention

Abstract

Aims: Patients using antithrombotic drugs after percutaneous coronary intervention (PCI) are at risk for bleeding and recurrent ischemia. We aimed to explore routine and tissue plasminogen activated (tPA) ROTEM results in a post-PCI population on dual antithrombotic treatment. Methods and Results: In this prospective cohort, 440 patients treated with double antithrombotic therapy after recent PCI and with ≥3 risk factors for either ischemic or bleeding complications were included and compared with a control group (n = 95) consisting of perioperative patients not using antithrombotic medication. Laboratory assessment, including (tPA) ROTEM, was performed one month post-PCI and bleeding/ischemic complications were collected over a five-month follow-up. Patients were stratified by antithrombotic regimen consisting of a P2Y12 inhibitor with either aspirin (dual antiplatelet therapy; DAPT, n = 323), a vitamin K antagonist (VKA, n = 69) or a direct oral anticoagulant (DOAC, n = 48). All post-PCI patients had elevated ROTEM clot stiffness values, but only the DAPT group additionally presented with a decreased fibrinolytic potential as measured with tPA ROTEM. Patients receiving anticoagulants had prolonged clotting times (CT) when compared to the control and DAPT group; EXTEM and FIBTEM CT could best discriminate between patients (not) using anticoagulants (AUC > 0.97). Furthermore, EXTEM CT was significantly prolonged in DAPT patients with bleeding complications during follow-up (68 [62-70] vs. 62 [57-68], p = 0.030). Conclusion: ROTEM CT has high potential for identifying anticoagulants and tPA ROTEM could detect a diminished fibrinolytic potential in patients using DAPT. Furthermore, the ability of EXTEM CT to identify patients at risk for bleeding may be promising and warrants further research.

Keywords: anticoagulants; antiplatelet drug; fibrinolysis; percutaneous coronary intervention; thromboelastometry (ROTEM®).

Figure 1

Flow diagram of study inclusion and stratification in treatment groups. DAPT, dual antiplatelet therapy consisting of aspirin and a P2Y12-inhibitor (P2Y12i); DOAC, direct oral anticoagulant; PCI, percutaneous coronary intervention; ROTEM, rotational thromboelastometry; VKA, vitamin K antagonist.

Figure 2

EXTEM (A–C), INTEM (D–F) and FIBTEM (G,H) results for clotting time (CT; A,D,G), clot formation time (CFT; B,E) and maximum clot firmness (MCF; C,F,H). Presented are median, IQR and 5–95 percentile whiskers. Dashed lines illustrate reference ranges according to the manufacturer. Significant differences (p < 0.008) compared to the control group are reported with an asterisk.

Figure 3

Clotting time (CT), lysis onset time (LOT) and lysis time (LT) tissue plasminogen activator (tPA) ROTEM. Presented are median, IQR and 5–95 percentile whiskers. Dashed lines illustrate tPA ROTEM reference range as determined by Kuiper et al. (20) Significant differences (p < 0.008) compared to the control group are reported with an asterisk.