Skip to main content
SpringerLink
Log in

Medical and Invasive Management of Coronary Artery Disease in Patients on Anticoagulants

  • Chapter
Controversies in Cardiology

  • 1044 Accesses

Abstract

The management of coronary artery disease in patients on anticoagulants represents a difficult clinical scenario. As more intense therapy is given, patients are expected to have less ischemic/thrombotic events, but they will have increased bleeding risks. In this chapter we examine the evidence base of the risks and benefits of combining antiplatelet therapy and anticoagulant therapy in both the primary and secondary prevention settings. While most of these data concern warfarin as the primary anticoagulant, we will review any data on the novel oral anticoagulants (NOACs) as well.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Lardizabal J, Joshi B, Ambrose J. The balance between anti-ischemic efficacy and bleeding risk of antithrombotic therapy in percutaneous coronary intervention: a Yin-Yang paradigm. J Invasive Cardiol. 2010;22:284–92.

    PubMed  Google Scholar 

  2. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71–86.

    Google Scholar 

  3. Hamberg M, Svensson J, Samuelsson B. Thromboxanes: a new group of biologically active compounds derived from prostaglandin endoperoxides. Proc Natl Acad Sci. 1975;72:2294–8.

    Article  Google Scholar 

  4. Fitzgerald GA. Mechanisms of platelet activation: thromboxane A2 as an amplifying signal for other agonists. Am J Cardiol. 1991;68:11B–5.

    Article  CAS  PubMed  Google Scholar 

  5. Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373:1849–60.

    Article  PubMed  Google Scholar 

  6. Peto R, Gray R, Collins R, et al. Randomised trial of prophylactic daily aspirin in British male doctors. Br Med J. 1988;296:313–6.

    Article  CAS  Google Scholar 

  7. Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005;352:1293–304.

    Article  CAS  PubMed  Google Scholar 

  8. Collaborative Group of the Primary Prevention Project. Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomised trial in general practice. Collaborative Group of the Primary Prevention Project. Lancet. 2001;357:89–95.

    Article  Google Scholar 

  9. Steering Committee of the Physicians’ Health Study Research Group. Final report on the aspirin component of the ongoing Physicians’ Health Study. N Engl J Med. 1989;321:129–35.

    Article  Google Scholar 

  10. The Medical Research Council’s General Practice Research Framework. Thrombosis prevention trial: randomised trial of low-intensity oral anticoagulation with warfarin and low-dose aspirin in the primary prevention of ischaemic heart disease in men at increased risk. Lancet. 1998;351:233–41.

    Article  Google Scholar 

  11. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet. 1998;351:1755–62.

    Article  CAS  PubMed  Google Scholar 

  12. Vandvik PO, Lincoff AM, Gore JM, et al. Primary and secondary prevention of cardiovascular disease: antithrombotic Therapy and Prevention of Thrombosis, 9th edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e637S–68.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  13. He J, Whelton PK, Vu B, et al. Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trials. JAMA. 1998;280:1930–5.

    Article  CAS  PubMed  Google Scholar 

  14. Bartolucci AA, Tendera M, Howard G. Meta-analysis of multiple primary prevention trials of cardiovascular events using aspirin. Am J Cardiol. 2011;107:1796–801.

    Article  CAS  PubMed  Google Scholar 

  15. Raju N, Sobieraj-Teague M, Hirsh J, et al. Effect of aspirin on mortality in the primary prevention of cardiovascular disease. Am J Med. 2011;124:621–9.

    Article  CAS  PubMed  Google Scholar 

  16. Berger JS, Lala A, Krantz MJ, et al. Aspirin for the prevention of cardiovascular events in patients without clinical cardiovascular disease: a meta-analysis of randomized trials. Am Heart J. 2011;162:115–24.

    Article  CAS  PubMed  Google Scholar 

  17. Seshasai SR, Wijesuriya S, Sivakumaran R, et al. Effect of aspirin on vascular and nonvascular outcomes: meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172:209–16.

    Article  CAS  PubMed  Google Scholar 

  18. Ogawa H, Nakayama M, Morimoto T, et al. Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial. JAMA. 2008;300:2134–41.

    Article  CAS  PubMed  Google Scholar 

  19. Fowkes FG, Price JF, Stewart MC, et al. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial. JAMA. 2010;303:841–8.

    Article  CAS  PubMed  Google Scholar 

  20. Belch J, MacCuish A, Campbell I, et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial. BMJ. 2008;337:a1840.

    Article  PubMed Central  PubMed  Google Scholar 

  21. Patrono C. Low-dose aspirin in primary prevention: cardioprotection, chemoprevention, both, or neither? Eur Heart J. 2013;34:3403–11.

    Article  CAS  PubMed  Google Scholar 

  22. Pignone M, Alberts MJ, Colwell JA, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: a position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Circulation. 2010;121:2694–701.

    Article  PubMed  Google Scholar 

  23. Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the US Preventative Services Task Force. Ann Intern Med. 2009;150:405–10.

    Article  PubMed  Google Scholar 

  24. Perk J, De Backer G, Gohlke H, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2012;33:1635–701.

    Article  CAS  PubMed  Google Scholar 

  25. Dentali F, Douketis JD, Lim W, Crowther M. Combined aspirin-oral anticoagulant therapy compared with oral anticoagulant therapy alone among patients at risk for cardiovascular disease. Arch Intern Med. 2007;167:117–1241.

    Article  CAS  PubMed  Google Scholar 

  26. Steinberg B, Kim S, Piccini J, et al. Use and associated risks of concomitant aspirin therapy with oral anticoagulation in patients with atrial fibrillation: insights from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Registry. Circulation. 2013;128:721–8.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  27. Butchart EG. Prosthetic heart valves. Cardiovascular thrombosis. 2nd ed. 1998. p. 395–414.

    Google Scholar 

  28. Massel D, Little S. Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database Syst Rev. 2013 (7):CD003464.

    Google Scholar 

  29. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57–185.

    Article  PubMed  Google Scholar 

  30. Fihn S, Gardin J, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60:e44–164.

    Article  PubMed  Google Scholar 

  31. Hart R, Pearce L, Aguilar M. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857–67.

    Article  PubMed  Google Scholar 

  32. Hamon M, Lemesle G, Tricot O, et al. Incidence, source, determinants, and prognostic impact of major bleeding in outpatients with stable coronary artery disease. J Am Coll Cardiol. 2014;64:1430–6.

    Article  PubMed  Google Scholar 

  33. Lamberts M, Gislason G, Lip G, et al. Antiplatelet therapy for stable coronary artery disease in atrial fibrillation patients taking an oral anticoagulant. Circulation. 2014;129:1577–85.

    Article  CAS  PubMed  Google Scholar 

  34. Dans A, Connolly S, Wallentin L, et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation. 2013;127:634–40.

    Article  CAS  PubMed  Google Scholar 

  35. Alexander J, Lopes R, Thomas L, et al. Apixaban vs. warfarin with concomitant aspirin in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J. 2014;35:224–32.

    Article  CAS  PubMed  Google Scholar 

  36. Schömig A, Neumann FJ, Kastrati A, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med. 1996;334:1084–9.

    Article  PubMed  Google Scholar 

  37. Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. N Engl J Med. 1998;339:1665–71.

    Article  CAS  PubMed  Google Scholar 

  38. Bertrand ME, Legrand V, Boland J, et al. Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The Full Anticoagulation Versus Aspirin and Ticlopidine (FANTASTIC) Study. Circulation. 1996;98:1597–603.

    Article  Google Scholar 

  39. Urban P, Macaya C, Rupprecht H, et al. Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients. The Multicenter Aspirin and Ticlopidine Trial after Intracoronary Stenting (MATTIS). Circulation. 1998;98:2126–32.

    Article  CAS  PubMed  Google Scholar 

  40. Connolly S, Pogue J, Hart R, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367:1903–12.

    Article  CAS  PubMed  Google Scholar 

  41. Karjalainen PP, Porela P, Ylitalo A, et al. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J. 2007;28:726–32.

    Article  CAS  PubMed  Google Scholar 

  42. Lamberts M, Gislason G, Olesen J, et al. Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. J Am Coll Cardiol. 2013;62:981–9.

    Article  CAS  PubMed  Google Scholar 

  43. Dewilde W, Oirbans T, Verheugt F, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomized, controlled trial. Lancet. 2013;381:1107–15.

    Article  CAS  PubMed  Google Scholar 

  44. Alexander JH, Lopes RD, James S, et al. Apixaban with antiplatelet therapy after acute coronary syndrome. N Engl J Med. 2011;365:699–708.

    Article  CAS  PubMed  Google Scholar 

  45. Oldgren J, Wallentin L, Alexander J, et al. New oral anticoagulants in addition to single or dual antiplatelet therapy after an acute coronary syndrome: a systematic review and meta-analysis. Eur Heart J. 2013;34:1670–80.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  46. Komocsi A, Vorobcsuk A, Kehl D, et al. Use of new-generation oral anticoagulant agents in patients receiving antiplatelet therapy after an acute coronary syndrome: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2012;172:1537–45.

    Article  PubMed  Google Scholar 

  47. January C, Wann L, Alpert J, et al. AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol. 2014;64(21):e1–76.

    Article  PubMed  Google Scholar 

  48. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS guideline on myocardial revascularization. Eur Heart J. 2014;35(37):2541–619. doi:10.1093/eurheartj/ehu278. Epub 2014 Aug 29.

    Article  PubMed  Google Scholar 

  49. Lip G, Windecker S, Hubert K, et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J. 2014;35(45):3155–79.

    Article  PubMed  Google Scholar 

  50. Sarafoff N, Martischnig A, Wealer J, et al. Triple therapy with aspirin, prasugrel, and vitamin K antagonists in patients with drug-eluting stent implantation and an indication for oral anticoagulation. J Am Coll Cardiol. 2013;61:2060–6.

    Article  CAS  PubMed  Google Scholar 

  51. Sambola A, Ferreira-Gonzalez I, Angel J, et al. Therapeutic strategies after coronary stenting in chronically anticoagulated patients: the MUSICA study. Heart. 2009;95:1483–8.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. UCSF Fresno Department of Cardiology, Community Regional Medical Center, Fresno, CA, USA

    Ryan Berg MD & Nabil Shafi MD

Authors
  1. Ryan Berg MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nabil Shafi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ryan Berg MD .

Editor information

Editors and Affiliations

  1. UCSF Fresno, Fresno, California, USA

    John A. Ambrose

  2. Department of Interventional Cardiology, Otamendi Hospital, Buenos Aires, Argentina

    Alfredo E. Rodríguez

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Berg, R., Shafi, N. (2015). Medical and Invasive Management of Coronary Artery Disease in Patients on Anticoagulants. In: Ambrose, J., Rodríguez, A. (eds) Controversies in Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-319-20415-4_12

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-20415-4_12

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-20414-7

  • Online ISBN: 978-3-319-20415-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation