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Hamostaseologie 2018; 38(04): 229-235
DOI: 10.1055/s-0038-1668165
Review Article
Schattauer GmbH Stuttgart

Antiplatelet Treatment for Catheter-Based Interventions in High-Risk Patients: Current Guidelines and Expert Opinion

Dominik Rath
1   Department of Cardiology and Cardiovascular Medicine, University of Tübingen, Tübingen, Baden-Württemberg, Germany
,
Meinrad Gawaz
1   Department of Cardiology and Cardiovascular Medicine, University of Tübingen, Tübingen, Baden-Württemberg, Germany
› Author Affiliations
Further Information

Publication History

10 April 2018

08 June 2018

Publication Date:
08 August 2018 (online)

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Abstract

Catheter-based interventions have revolutionized treatment of both coronary artery disease and aortic valve disease. Yet, these procedures are accompanied by thromboembolic and bleeding complications. Antiplatelet agents and anticoagulants with tolerable risk of bleeding complications are required to protect from recurrent thromboembolic events. Although guidelines for antithrombotic treatment in patients undergoing percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR) are available, scarce evidence exists regarding therapeutic recommendations for patients at high risk for thromboembolic events or major bleeding. The choice of optimal antiplatelet therapy after PCI in patients with complex coronary artery disease and concomitant atrial fibrillation often poses a clinical challenge. The antiplatelet therapy in patients undergoing TAVR is so far based mostly on expert consensus. The present review addresses state-of-the-art antithrombotic therapy, particularly focusing on patients at high risk of thromboembolic and bleeding events, and aims to provide recommendations for clinical practice.

Zusammenfassung

In der modernen Medizin werden zunehmend Katheterverfahren zur Behandlung der koronaren Herzerkrankung sowie der Aortenstenose eingesetzt. Obwohl diese Verfahren ein generell gutes Sicherheitsprofil aufweisen, besteht die Gefahr für thromboembolische sowie Blutungsereignisse. Moderne Antikoagulanzien sowie Thrombozytenaggregationshemmer müssen zuverlässig vor thromboembolischen Komplikationen schützen, dürfen jedoch das Blutungsrisiko nicht exorbitant erhöhen. Empfehlungen der großen kardiologischen Gesellschaften zum Einsatz antithrombozytärer Therapie im Rahmen der perkutanen Koronarintervention (PCI) sowie dem interventionellen Aortenklappenersatz (TAVI) liegen vor. Jedoch existieren kaum Richtlinien zum Umgang mit Patienten, welche ein sehr hohes thromboembolisches oder Blutungsrisiko aufweisen. Die richtige antithrombozytäre Therapie bei Patienten mit komplexer koronarer Herzerkrankung (KHK) sowie KHK mit begleitendem Vorhofflimmern stellt nach wie vor eine große Herausforderung für den behandelnden Arzt dar. Richtlinien zur antithombozytären Therapie im Rahmen der TAVI beziehen hauptsächlich Expertenmeinungen ein. Diese Übersichtsarbeit beleuchtet die moderne antithrombotische Therapie mit speziellem Augenmerk auf Patienten mit hohem Risiko für thromboembolische sowie Blutungskomplikationen und stellt dem behandelnden Arzt Konzepte für die Therapie dieser Hochrisikokollektive zur Verfügung.

Keywords

PCI - TAVR - atrial fibrillation - antiplatelet therapy

Schlüsselwörter

PTCA - TAVI - Vorhofflimmern - antithrombozytäre Therapie
 

  • References

  • 1 Mann DL, Zipes DP, Libby P, Bonow RO. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: Elsevier Saunders; 2015
    Google Scholar
  • 2 Hou Y, Carrim N, Wang Y, Gallant RC, Marshall A, Ni H. Platelets in hemostasis and thrombosis: Novel mechanisms of fibrinogen-independent platelet aggregation and fibronectin-mediated protein wave of hemostasis. J Biomed Res 2015; 29: 29
    PubMedGoogle Scholar
  • 3 Jamasbi J, Ayabe K, Goto S, Nieswandt B, Peter K, Siess W. Platelet receptors as therapeutic targets: Past, present and future. Thromb Haemost 2017; 117 (07) 1249-1257
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Turner NA, Nolasco L, Ruggeri ZM, Moake JL. Endothelial cell ADAMTS-13 and VWF: production, release, and VWF string cleavage. Blood 2009; 114 (24) 5102-5111
    CrossrefPubMedGoogle Scholar
  • 5 Khan N, Farooq AD, Sadek B. Investigation of cyclooxygenase and signaling pathways involved in human platelet aggregation mediated by synergistic interaction of various agonists. Drug Des Devel Ther 2015; 9: 3497-3506
    PubMedGoogle Scholar
  • 6 Bruhn HA, Hach-Wunderle V, Schambeck CM, Scharf RE. Hämostaseologie für die Praxis: Sicher durch den klinischen Alltag. Schattauer; 2010
    Google Scholar
  • 7 Nylander S, Schulz R. Effects of P2Y12 receptor antagonists beyond platelet inhibition–comparison of ticagrelor with thienopyridines. Br J Pharmacol 2016; 173 (07) 1163-1178
    CrossrefPubMedGoogle Scholar
  • 8 Tello-Montoliu A, Tomasello SD, Ueno M, Angiolillo DJ. Antiplatelet therapy: thrombin receptor antagonists. Br J Clin Pharmacol 2011; 72 (04) 658-671
    CrossrefPubMedGoogle Scholar
  • 9 Morrow DA, Braunwald E, Bonaca MP. , et al; TRA 2P–TIMI 50 Steering Committee and Investigators. Vorapaxar in the secondary prevention of atherothrombotic events. N Engl J Med 2012; 366 (15) 1404-1413
    CrossrefPubMedGoogle Scholar
  • 10 Rath D, Chatterjee M, Müller I. , et al. Platelet expression of transforming growth factor beta 1 is enhanced and associated with cardiovascular prognosis in patients with acute coronary syndrome. Atherosclerosis 2014; 237 (02) 754-759
    CrossrefPubMedGoogle Scholar
  • 11 Springer TA. von Willebrand factor, Jedi knight of the bloodstream. Blood 2014; 124 (09) 1412-1425
    Google Scholar
  • 12 Sones Jr FM, Shirey EK. Cine coronary arteriography. Mod Concepts Cardiovasc Dis 1962; 31: 735-738
    PubMedGoogle Scholar
  • 13 Meier B. Andreas Roland Grüntzig, the man. Eur Heart J 2017; 38 (28) 2161-2163
    CrossrefPubMedGoogle Scholar
  • 14 Roffi M, Patrono C, Collet JP. , et al; ESC Scientific Document Group. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37 (03) 267-315
    CrossrefPubMedGoogle Scholar
  • 15 Kirchhof P, Benussi S, Kotecha D. , et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18 (11) 1609-1678
    CrossrefPubMedGoogle Scholar
  • 16 Bhatt DL, Eagle KA, Ohman EM. , et al; REACH Registry Investigators. Comparative determinants of 4-year cardiovascular event rates in stable outpatients at risk of or with atherothrombosis. JAMA 2010; 304 (12) 1350-1357
    CrossrefPubMedGoogle Scholar
  • 17 Nakatani D, Sakata Y, Suna S. , et al; Osaka Acute Coronary Insufficiency Study (OACIS) Investigators. Incidence, predictors, and subsequent mortality risk of recurrent myocardial infarction in patients following discharge for acute myocardial infarction. Circ J 2013; 77 (02) 439-446
    CrossrefPubMedGoogle Scholar
  • 18 Bonaca MP, Bhatt DL, Cohen M. , et al; PEGASUS-TIMI 54 Steering Committee and Investigators. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med 2015; 372 (19) 1791-1800
    CrossrefPubMedGoogle Scholar
  • 19 Bhatt DL, Fox KA, Hacke W. , et al; CHARISMA Investigators. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006; 354 (16) 1706-1717
    CrossrefPubMedGoogle Scholar
  • 20 Valgimigli M, Bueno H, Byrne RA. , et al; ESC Scientific Document Group; ESC Committee for Practice Guidelines (CPG); ESC National Cardiac Societies. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39 (03) 213-260
    CrossrefPubMedGoogle Scholar
  • 21 Connolly SJ, Eikelboom JW, Bosch J. , et al; COMPASS investigators. Rivaroxaban with or without aspirin in patients with stable coronary artery disease: an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; pii: S0140-6736(17)32458-3
    PubMedGoogle Scholar
  • 22 Sibbing D, Aradi D, Jacobshagen C. , et al; TROPICAL-ACS Investigators. Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): a randomised, open-label, multicentre trial. Lancet 2017; 390 (10104): 1747-1757
    CrossrefPubMedGoogle Scholar
  • 23 Ruiz-Nodar JM, Marín F, Hurtado JA. , et al. Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis. J Am Coll Cardiol 2008; 51 (08) 818-825
    CrossrefPubMedGoogle Scholar
  • 24 Hansen ML, Sørensen R, Clausen MT. , et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 2010; 170 (16) 1433-1441
    CrossrefPubMedGoogle Scholar
  • 25 Lamberts M, Olesen JB, Ruwald MH. , et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study. Circulation 2012; 126 (10) 1185-1193
    CrossrefPubMedGoogle Scholar
  • 26 Windecker S, Kolh P, Alfonso F. , et al; Authors/Task Force members. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35 (37) 2541-2619
    CrossrefPubMedGoogle Scholar
  • 27 Kirchhof P, Benussi S, Kotecha D. , et al; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37 (38) 2893-2962
    CrossrefPubMedGoogle Scholar
  • 28 Dans AL, Connolly SJ, Wallentin L. , et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation 2013; 127 (05) 634-640
    CrossrefPubMedGoogle Scholar
  • 29 Dewilde WJM, Oirbans T, Verheugt FWA. , et al; WOEST study investigators. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381 (9872): 1107-1115
    CrossrefPubMedGoogle Scholar
  • 30 Zhu W, Guo L, Liu F. , et al. Efficacy and safety of triple versus dual antithrombotic therapy in atrial fibrillation and ischemic heart disease: a systematic review and meta-analysis. Oncotarget 2017; 8 (46) 81154-81166
    CrossrefPubMedGoogle Scholar
  • 31 Gibson CM, Mehran R, Bode C. , et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med 2016; 375 (25) 2423-2434
    CrossrefPubMedGoogle Scholar
  • 32 Cannon CP, Bhatt DL, Oldgren J. , et al; RE-DUAL PCI Steering Committee and Investigators. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med 2017; 377 (16) 1513-1524
    CrossrefPubMedGoogle Scholar
  • 33 Baumgartner H, Falk V, Bax JJ. , et al; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017; 38 (36) 2739-2791
    CrossrefPubMedGoogle Scholar
  • 34 Vavuranakis M, Siasos G, Zografos T. , et al. Dual or single antiplatelet therapy after transcatheter aortic valve implantation? A systematic review and meta-analysis. Curr Pharm Des 2016; 22 (29) 4596-4603
    CrossrefPubMedGoogle Scholar
  • 35 Chakravarty T, Søndergaard L, Friedman J. , et al; RESOLVE; SAVORY Investigators. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet 2017; 389 (10087): 2383-2392
    CrossrefPubMedGoogle Scholar
  • 36 Makkar RR, Fontana G, Jilaihawi H. , et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med 2015; 373 (21) 2015-2024
    CrossrefPubMedGoogle Scholar
  • 37 Rodés-Cabau J, Masson JB, Welsh RC. , et al. Aspirin versus aspirin plus clopidogrel as antithrombotic treatment following transcatheter aortic valve replacement with a balloon-expandable valve: The ARTE (Aspirin Versus Aspirin + Clopidogrel Following Transcatheter Aortic Valve Implantation) randomized clinical trial. JACC Cardiovasc Interv 2017; 10 (13) 1357-1365
    CrossrefPubMedGoogle Scholar
  • 38 Mangieri A, Jabbour RJ, Montalto C. , et al. Single-antiplatelet therapy in patients with contraindication to dual-antiplatelet therapy after transcatheter aortic valve implantation. Am J Cardiol 2017; 119 (07) 1088-1093
    CrossrefPubMedGoogle Scholar
  • 39 Généreux P, Cohen DJ, Mack M. , et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. J Am Coll Cardiol 2014; 64 (24) 2605-2615
    CrossrefPubMedGoogle Scholar