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Warfarin plus antiplatelet agent viable option for mechanical valves after PCI
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There are few data on the optimal antiplatelet and antithrombotic regimen for patients with mechanical valves after PCI, but warfarin plus a single antiplatelet agent, likely clopidogrel, may be the best option, experts wrote in a Viewpoint published in JAMA Cardiology.
Cian P. McCarthy, MB, BCh, BAO, from the department of medicine at Massachusetts General Hospital, Subodh Verma, MD, PhD, from the division of cardiac surgery at St. Michael’s Hospital and the University of Toronto, and Cardiology Today’s Intervention Chief Medical Editor Deepak L. Bhatt, MD, MPH, from Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, reviewed the literature on the challenging clinical problem.
“[Dual antiplatelet therapy] and oral anticoagulant therapy are deemed necessary to reduce the risks of stent thrombosis and thromboembolism, respectively, but these potential benefits need to be balanced against the risk of bleeding when combining these agents,” the authors wrote. “While strides have been made to clarify the optimal regimen in patients with [atrial fibrillation] undergoing PCI, patients with mechanical heart valves are more challenging, with greater thromboembolic risk.”
According to McCarthy and colleagues, randomized controlled trials are needed to establish a regimen capable of minimizing bleeding risk while not elevating stent thrombosis or thromboembolic event risk. Currently, there is no model for physicians in the optimal antiplatelet/antithrombotic regimen specific to this cohort, they wrote.
“When undertaking these efforts, it is important to comprehend that patients with mechanical heart valves are a diverse group, with thromboembolic risk higher among patients with mechanical mitral valves compared with those with mechanic aortic valves,” McCarthy and colleagues wrote.
Randomized controlled trial evidence suggests this patient population should receive second-generation drug-eluting stents instead of bare-metal stents, the authors wrote.
Complicating matters is that non-vitamin K oral anticoagulants are contraindicated in patients with mechanical heart valves, leaving warfarin as the preferred anticoagulant choice, they wrote.
The authors suggested a combination consisting of warfarin with the addition of single antiplatelet agent, likely clopidogrel, to minimize risk for stent thrombosis.
A proton pump inhibitor could be added to the therapy to reduce risk for gastrointestinal hemorrhage, they wrote.
According to the authors, the preferred duration for the regimen would be 1 year in patients with ACS and 6 months in patients with elective PCI. For the latter group, anticoagulation alone would be administered after 6 months, they wrote.
“This approach would surely reduce bleeding vs. an indiscriminate extended use of triple antithrombotic therapy and, hopefully, also minimize the occurrence of less frequent but potentially catastrophic outcomes such as thromboembolism or stent thrombosis,” McCarthy and colleagues wrote. – by Dave Quaile
Disclosure: Bhatt reports financial ties with various device and pharmaceutical companies. McCarthy and Verma report no relevant financial disclosures.
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