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Percutaneous coronary intervention: antithrombotic therapy

This FOCUS session aimed to discuss difficult and unresolved issues in antithrombotic treatment. Three interesting cases were presented and a rich discussion followed both among the panelists and from the audience.

Marko Noč (Ljubljana, Slovenia) presented a patient with a recent history of stroke, currently on long-term warfarin treatment, who presented with exercise-induced angina + ischemia on nuclear imaging. The patient was admitted for coronary angiography with an INR value of 2.3 and the discussion was mainly about the catheterization techniques. Most discussants preferred a radial approach without interrupting warfarin over the other options (femoral approach + closure device, femoral approach + manual compression, warfarin interruption with low molecular weight heparin “bridging”).

Andreas Baumbach (Bristol, United Kingdom) demonstrated a patient (treated by his hospital colleague) with metallic aortic valve prosthesis on long term warfarin therapy, who presented to a PCI hospital with evolving anterior STEMI within 2 hours of symptom onset. Primary PCI with bare metal stent(s) was the treatment of choice voted by vast majority of the audience. The operator surprisingly used drug eluting stent for this LAD with good immediate result. Most discussion was around further antithrombotic medication – triple combination of warfarin + aspirin + clopidogrel for next 12 months was the prevailing recommendation of the audience and also the reality in this case.

However, this patient came back to the hospital with hypotension and melena. After negative endoscopy and four blood transfusions, triple antithrombotic medication was re-started. The patient came back again with melena. After this second melena, aspirin was stopped and patient continued to use only warfarin + clopidogrel.

Don Poldermans (Rotterdam, the Netherlands) presented an elderly diabetic lady two months after implantation of three drug eluting stents, currently admitted to hospital for newly diagnosed colon cancer. Surgery was scheduled for the cancer and the question was how to bridge the critical perioperative period with antithrombotic medication. D.Poldermans discussed available literature and his center experience and P. Widimsky presented the results of his quick survey among 6 experienced cardiologists – they recommended 6 different treatment schemes for this period, varying from interrupting aspirin + clopidogrel 7 days before abdominal surgery to continuing both drugs without any interruption during surgery. S. Silber added a seventh treatment scheme – he suggested to “bridge” the critical period by epifibatide or tirofiban.

The session was very interactive, ESC guidelines were discussed and the need for more data on these difficult situations was stressed.




Percutaneous coronary intervention: antithrombotic therapy

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.