ABSTRACT
American College of Cardiology/American Heart Association guidelines for antithrombotic therapy during percutaneous coronary intervention • Rescue percutaneous coronary intervention • Percutaneous coronary intervention in patients on chronic oral anticoagulation • Percutaneous coronary intervention in patients with chronic liver disease or congenital coagulopathy • Percutaneous coronary intervention in patients with renal insufficiency • Percutaneous coronary intervention in patients with thrombocytopenia or disorders of platelet function • Summary
In patients undergoing percutaneous coronary intervention (PCI), adjunctive therapy with anticoagulation and inhibitors of platelet activation and/or aggregation is indispensable in protecting against acute thrombosis of the treated vessel, improving survival, reducing periprocedural myocardial infarction (MI), and the need for urgent target vessel revascularization. At the same time, aggressive anticoagulant and antiplatelet therapy may be associated with increased risk of bleeding, especially in older patients and patients with renal insufficiency. Balancing between the prevention of ischemic events versus minimizing serious bleeding is a key challenge the interventional cardiologist faces on a case-by-case basis. This issue becomes even more challenging in patients referred for PCI who have pre-existent congenital or acquired coagulation and/or platelet abnormalities. This real-life scenario gives an excellent example of such a situation:
A 46 year old man with a history of hypertension, hyperlipidemia and hemophilia A is admitted to hospital with typical intermittent angina pain of oneday duration, ST segment depression in precordial leads on electrocardiogram (ECG) and mildly elevated troponin I. He also has a history of severe bleeding, last occurring 3 months ago. Coronary arteriography reveals one-vessel disease, with a discrete severe mid-left anterior descending artery stenosis, associated with some haziness. Coronary intervention is indicated.
