The WOEST 2 registry : A prospective registry on antithrombotic therapy in atrial fibrillation patients undergoing percutaneous coronary intervention.

BACKGROUND: Patients on oral anticoagulants (OACs) undergoing percutaneous coronary intervention (PCI) also require aspirin and a P2Y12 inhibitor (triple therapy). However, triple therapy increases bleeding. The use of non-vitamin K antagonist oral anticoagulants (NOACs) and stronger P2Y12 inhibitors has increased. The aim of our study was to gain insight into antithrombotic management over time. METHODS: A prospective cohort study of patients on OACs for atrial fibrillation or a mechanical heart valve undergoing PCI was performed. Thrombotic outcomes were myocardial infarction, stroke, target-vessel revascularisation and all-cause mortality. Bleeding outcome was any bleeding. We report the 30-day outcome. RESULTS: The mean age of the 758 patients was 73.5 ± 8.2 years. The CHA2DS2-VASc score was ≥ 3 in 82% and the HAS-BLED score ≥ 3 in 44%. At discharge, 47% were on vitamin K antagonists (VKAs), 52% on NOACs, 43% on triple therapy and 54% on dual therapy. Treatment with a NOAC plus clopidogrel increased from 14% in 2014 to 67% in 2019. The rate of thrombotic (4.5% vs 2.0%, p = 0.06) and bleeding (17% vs. 14%, p = 0.42) events was not significantly different in patients on VKAs versus NOACs. Also, the rate of thrombotic (2.9% vs 3.4%, p = 0.83) and bleeding (18% vs 14%, p = 0.26) events did not differ significantly between patients on triple versus dual therapy. CONCLUSIONS: Patients on combined oral anticoagulation and antiplatelet therapy undergoing PCI are elderly and have both a high bleeding and ischaemic risk. Over time, a NOAC plus clopidogrel became the preferred treatment. The rate of thrombotic and bleeding events was not significantly different between patients on triple or dual therapy or between those on VKAs versus NOACs.

How cardiologists manage antithrombotic treatment of patients with atrial fibrillation undergoing percutaneous coronary stenting: the WOEST survey 2018.

BACKGROUND: Antithrombotic treatment choices are complicated when patients have both atrial fibrillation (AF) and acute coronary syndrome and/or undergo percutaneous coronary intervention (PCI). In this study, we aimed to gain insight into antithrombotic management strategies in daily clinical practice. METHODS: We invited interventional cardiologists to complete the WOEST (What is the Optimal antiplatElet & Anticoagulant Therapy in Patients With Oral Anticoagulation and Coronary StenTing) survey 2018. In this questionnaire, we presented a patient with a non-ST-elevation myocardial infarction (NSTEMI) and an elective PCI case. RESULTS: The results were based on 118 completed questionnaires (response rate 69.4%). In the case of the AF patient with NSTEMI, most cardiologists indicated they would initiate dual antiplatelet therapy (acetylsalicylic acid and clopidogrel) and continue non-vitamin K antagonist oral anticoagulant (NOAC) therapy at admission and during coronary angiography/PCI. At discharge, 70.3% would prescribe triple antithrombotic therapy (oral anticoagulation, acetylsalicylic acid and clopidogrel), mostly for 1 month. One year after NSTEMI, 83.1% would cancel the antiplatelet therapy and prescribe NOAC monotherapy. For the AF patient undergoing elective PCI, 51.7% would start dual antiplatelet therapy prior to the procedure and 52.5% would discontinue NOAC therapy prior to the PCI. At discharge, 55.1% would start triple antithrombotic therapy. Furthermore, 25.4% responded they routinely prescribe a reduced dose of NOAC after discharge. One year after PCI, 89.0% would continue NOAC monotherapy. CONCLUSION: The WOEST survey demonstrated heterogeneity in antithrombotic management strategies among interventional cardiologists. This observed variety mirrors the heterogeneity of the many guidelines and consensus documents. Further research is needed to guide patient-tailored medicine for AF patients undergoing PCI.

Dual antiplatelet therapy in the anticoagulated patient undergoing percutaneous coronary intervention risks, benefits, and unanswered questions.

A commonly encountered scenario is the patient with atrial fibrillation (AF) on oral anticoagulation (OAC) who either develops an acute coronary syndrome or has to undergo percutaneous coronary intervention with stent placement. In such patients, separate indications suggest combining OAC and dual antiplatelet therapy (DAPT). This approach, however, increases the risk of bleeding as well as thromboembolic risk if bleeding does not occur. For optimal clinical results, the risks and benefits of all possible treatment options should be determined based on the best available data. This review provides an overview of the most recent data regarding the optimal treatment of AF patients with an indication for combined treatment with OAC and DAPT.

Early double stent thrombosis associated with clopidogrel hyporesponsivenesss.

A 57-year-old male patient without cardiovascular history suffered an acute myocardial infarction and underwent drug-eluting stent implantation in the left anterior descending artery. A few days later, the right coronary artery was also stented (drug-eluting stent). Three days later, he was re-admitted to our hospital in cardiogenic shock. Emergent coronary angiography showed total occlusion of both stents. Platelet function analysis (PFA) showed attenuated platelet inhibition in response to clopidogrel treatment. The patient was the carrier of a loss-of-function polymorphism in the CYP2C19 gene, which has been associated with increased incidence of adverse thrombotic events. Antiplatelet therapy was switched to prasugrel and PFA revealed an adequate antiplatelet effect.

'Ins' and 'outs' of triple therapy: Optimal antiplatelet therapy in patients on chronic oral anticoagulation who need coronary stenting.

Chronic oral anticoagulant treatment is obligatory in patients (class I) with mechanical heart valves and in patients with atrial fibrillation with CHADS2 score >1. When these patients undergo percutaneous coronary intervention with placement of a stent, there is also an indication for treatment with aspirin and clopidogrel. Unfortunately, triple therapy is known to increase the bleeding risk. For this group of patients, the bottom line is to find the ideal therapy in patients with indications for both chronic anticoagulation therapy and percutaneous intervention to prevent thromboembolic complications such as stent thrombosis without increasing the risk of bleeding. (Neth Heart J 2010;18:444-50.).

Cardiac surgery in a patient with essential thrombocythemia: a case report.

Patients with essential thrombocythemia (ET) are at increased risk of developing arterial thrombosis. We report a case of a 36-year-man with unstable angina in the presence of occlusion of two coronary arteries with insufficient collateral perfusion. We also found essential thrombocythemia in this patient. The patient underwent coronary artery bypass grafting (CABG). Ten days before surgery, the aspirin was replaced by a prophylactic dose of low-molecular-weight heparin. Postoperative follow-up was complicated by pulmonary embolisms and a cardiac tamponade. We conclude that ET is a risk factor for coronary heart disease that should be treated with aspirin. If a patient needs CABG, aspirin should be continued because of the high risk of thromboembolic events in the high-risk ET patients. (Neth Heart J 2010;18:378-80.).

An anomalous right coronary artery originating from the mid portion of the left descending artery.

We report on a 76-year old patient in which a very rare coronary anomaly was found.

Aorta-atrial fistula, a rare complication of prosthetic valve endocarditis.

A 51-year-old male with a history of a mechanical Carbomedics aortic and mitral valve replacement in 2003 and several re-operations because of endocarditis of the mitral valve in 2007 presented with heart failure 68 days after operation. Echocardiography confirmed the presence of a fistulous connection between the aorta and the left atrium. Because of the multiple surgical interventions and high operative risk, an initial conservative medical treatment was initiated and the clinical course was uneventful to this date.

Renovascular hypertension associated with neurofibromatosis: a case report.

Although vascular involvement in type 1 neurofibromatosis (NF1) is rare, it may lead to renal artery stenosis and renovascular hypertension (RVH). RVH may be treated using antihypertensive drugs, percutaneous transluminal renal angioplasty (PTRA), surgical reconstruction of the renal artery, or nefrectomy. In NF1 the results of PTRA are less predictable than in cases of fibromuscular dysplasia and atherosclerosis. We report a case of RVH associated with NF1. Despite administration of multiple antihypertensive drugs blood pressure remained uncontrolled. Selective left renal arteriography demonstrated two consecutive high-grade stenotic lesions with post-stenotic aneurysmal dilatation treated successfully with balloon dilatation. During the ensuing 2 year follow up complete normalization of blood pressure was observed. This case illustrates that endovascular therapy may be beneficial and should be considered a reasonable first option in these patients. However vascular involvement in NF may be progressive and therefore always requires continuing follow up.