Which antithrombotic to use during PCI?

Abstract

With >2 million percutaneous coronary intervention (PCI) procedures performed worldwide annually, the optimal choice of antithrombotic therapy during PCI is of critical importance. There are three main choices for antithrombotic therapy during PCI: (i) heparin alone: (ii) heparin + glycoprotein (GP) IIb IIIa inhibitor; or (iii) bivalirudin. The use of heparin during PCI is based upon a clinical rationale that PCI is intensively thrombogenic and an anticoagulant would be essential to avoid high rates of thrombotic occlusion of the coronary artery. As the only intravenous anticoagulant available a few decades ago, heparin quickly became standard practice and so until very recently there have been no trials comparing heparin vs. placebo. A recent placebo-controlled trial of heparin1 (70–100 U/kg, n = 700) in patients with chronic coronary artery disease undergoing elective PCI and receiving dual antiplatelet therapy demonstrated increased overall bleeding (rates of 1.7% heparin vs. 0% placebo, P = 0.048) with no difference in major bleeding (0 vs. 0) with heparin and no significant difference in the composite of death, myocardial infarction (MI), or urgent lesion revascularization [3.7% heparin vs. 2.0% placebo, odds ratio (OR) 1.92; 95% confidence interval (CI) 0.76–4.88, P = 0.17]. Further trials of the value of heparin are needed in elective PCI, and at the minimum suggest that lower doses of heparin may be just as effective with less bleeding compared with standard or high dose heparin during PCI. In a large number of trials, GP IIb IIIa inhibitors have been evaluated vs. placebo in patients receiving heparin and aspirin undergoing PCI. A meta-analysis of 21 trials ( n = 23 941) comparing heparin + GP IIb IIIa inhibitor vs. heparin alone showed that GP IIb IIIa inhibitors reduced death at 30 days (0.8% vs. 1.2%, OR 0.72; 95% CI 0.56–0.94), reduced MI events (4.5% vs. …