NEW YORK (Reuters Health) – Results of a meta-analysis indicate that anticoagulation may not need to be interrupted in patients undergoing elective coronary angiography. However, the quality of the evidence is not sufficient to be definitive, the researchers conclude.
Dr. James D. Douketis, with McMaster University and St Joseph’s Healthcare in Hamilton, Ontario, Canada describe their study in the October issue of Chest.
The authors point out that bleeding risk poses a challenge when patients on vitamin K antagonist (VKA) anticoagulation require invasive procedures, whereas suspending anticoagulation therapy may increase the risk of atherothrombotic events.
Currently, they explain, “Periprocedural anticoagulation strategies include interrupting VKA therapy for 5 days prior to the procedure; interrupting VKA and administering bridging anticoagulation, typically with a low-molecular-weight heparin; or continuing the VKA at the time of the procedure.”
To determine the incidence of bleeding during elective coronary angiography, with or without PCI, in patients who had VKA interrupted or uninterrupted, the researchers identified eight relevant studies. However, “Most were of moderate to very low quality.”
A meta-analysis of the data indicated that uninterrupted VKA therapy was associated with an access-site bleeding complication rate of 4%. The rate ranged from 2% to 14% with interrupted strategies, although high heterogeneity between studies meant the rates could not be pooled.
“The only atherothrombotic events occurred in one study where there was one stroke in the uninterrupted VKA group and two strokes in the interrupted VKA group,” according to the report.
Dr. Douketis and colleagues conclude, “Our main finding is that a periprocedural strategy of uninterrupted anticoagulation in VKA-treated patients who require coronary angiography may be at least as safe as a strategy of VKA interruption with or without bridging therapy.”
Still, they emphasize that well designed randomized trials are needed to compare strategies.
Until those studies are done, the authors of an accompanying editorial write, “The cornerstone of safely managing anticoagulated patients through procedures such as PCI will be to tailor therapy to the needs of individual patients, based on their relative risks of thromboembolism and bleeding.”
Drs. Benjamin J. Wrigley, Eduard Shantsila, and Gregory Y. H. Lip with the University of Birmingham Centre for Cardiovascular Sciences, UK, suggest that the HAS-BLED bleeding risk assessment tool may be useful in that regard.
Reference:
Safety of Uninterrupted Anticoagulation in Patients Requiring Elective Coronary Angiography With or Without Percutaneous Coronary Intervention
A Systematic Review and Metaanalysis
Chest 2010; 138:840–847.
