PCI patients taking oral anticoagulants may not need aspirinBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1052 (Published 20 February 2013) Cite this as: BMJ 2013;346:f1052
The management of percutaneous coronary intervention (PCI) in people taking long term oral anticoagulants involves a difficult balancing act, so that the risk of bleeding is minimised while protection against thromboembolic events is maximised. One preliminary trial suggests that clopidogrel alone causes fewer bleeds in these patients than clopidogrel plus aspirin (19.4% (54/279) v 44.4% (126/284); hazard ratio 0.36, 95% CI 0.26 to 0.50). Dropping the aspirin didn’t increase thromboembolic events over one year and was associated with fewer deaths overall (2.5% v 6.3%; 0.39, 0.16 to 0.93). All participants continued their long term oral anticoagulants throughout the trial. Most (69%) participants had atrial fibrillation or flutter.
These findings could overturn current recommendations, but we need further reassurance before switching everyone from two antiplatelet agents to just one, says a linked comment (doi:10.1016/S0140-6736(13)60054-9). Dropping aspirin didn’t prevent major bleeds in two out of three analyses, and the trial wasn’t powerful enough to rule out extra stent thromboses in patients taking clopidogrel alone.
The trial was open label and designed pragmatically to reflect real world practice. Most of the participants had drug eluting stents, not the bare metal stents recommended for people taking oral anticoagulants. They needed longer treatment with antiplatelet agents as a result. Doctors didn’t always use modern measures to prevent bleeding, such as radial artery access (only 25-27% of patients) and proton pump inhibitors (34-39%). Overall rates of bleeding were higher than expected.
Practice shouldn’t change just yet, says the comment.
Cite this as: BMJ 2013;346:f1052