11 - Anticoagulation in Percutaneous Coronary Intervention

Abstract

The past two decades have seen the introduction of a number of new anticoagulant agents aimed at optimizing ischemic protection while minimizing systemic bleeding complications. Heparin, enoxaparin, and bivalirudin are the most widespread anticoagulant agents used in current PCI practice, and these form the basis of recommendations from major society guidelines. The coagulation cascade reflects the complex interplay among the coagulation proteins, platelets, and cellular phospholipid membranes of not only vascular endothelial cells but of a wide range of inflammatory cells that include monocytes and vascular smooth muscle cells. In patients with ST-elevation myocardial infarction (STEMI), despite a significant body of randomized controlled data, there remains clinical equipoise with regard to the anticoagulant choice primarily to significant heterogeneity between clinical trials. As a result, heparin, enoxaparin, or bivalirudin are acceptable options in patients with STEMI and are supported by major society guidelines. Similarly, a large body of heterogeneous, and at times conflicting, clinical trial evidence exists for the use of various anticoagulant agents in patients with non–ST-elevation acute coronary syndrome (NSTEACS) in whom an invasive approach has been planned. Heparin, enoxaparin, fondaparinux (with adjunctive heparin), and bivalirudin are all acceptable options for periprocedural anticoagulation and have been given a class 1 recommendation in the both the ESC and ACC guidelines. Anticoagulation remains the standard of care during elective PCI based on the atherothrombotic potential of stable plaque and the prothrombotic effect of stenting. This is despite two RCTs of REPLACE-2 and CIAO that challenged this assertion, although both trials have limitations. The choice of anticoagulation is more difficult because of the paucity of large RCTs with the currently available agents.