View source for PCI in the patient at risk of bleeding

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==Overview==
The goal of antiplatelet therapy for patients undergoing percutaneous coronary intervention (PCI) is to reduce the risk of ischaemic events without increasing the risk of bleeding. Balancing between the prevention of ischemic events versus minimizing serious bleeding complications holds the key role and remains as one of the biggest dilemmas in the interventional cardiology practice <ref>Gibson CM. Has my patient achieved adequate myocardial reperfusion? Circulation 2003;108:504-7.</ref> <ref>Mejevoi N, Durand JB, Cohen M. Patients with impaired hemostasis requiring cardiac catheterization and coronary intervention in Common Clinical Dilemmas in Percutaneous Coronary Interventions. Eulógio E Martinez, Pedro A Lemos, Andrew TL Ong, Patrick W Serruys, Taylor & Francis, ISBN 9781841846095</ref>

Standard antiplatelet and anticoagulation therapy should be provided to these group of patients unless absolutely contraindicated, demonstrating overall benefit, especially in patients with [[acute coronary syndromes]] ([[ACS]]). 

==ACCF/AHA/SCAI 2011 Guideline for Percutaneous Coronary Intervention: Bleeding Risk<ref name="pmid22070837">{{cite journal |author=Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH |title=2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |journal=[[Journal of the American College of Cardiology]] |volume=58 |issue=24 |pages=2550–83 |year=2011 |month=December|pmid=22070837|doi=10.1016/j.jacc.2011.08.006|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(11)02875-0|accessdate=2011-12-08|url=http://content.onlinejacc.org/cgi/reprint/58/24/2550.pdf|PDF}}</ref> (DO NOT EDIT)==

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<nowiki>"</nowiki>'''1.''' All patients should be evaluated for risk of bleeding before PCI. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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The risk of bleeding can be significantly decreased in these groups with an individualized approach as; 

*Avoiding routine use of [[glycoprotein IIb/IIIa inhibitor]]s
*Considering the level of emergency of the procedure
*Evaluating the mechanism of the preexisting hemostasis disorder 
*Careful monitoring and correction of the deficient factors
*Understanding the mechanism of drug action
*Proper dosing for half-life specifications, 
*Adequate knowledge on drug metabolism, 
*Respective dose adjustment for excretion route 
*Experience on specific indications for the antithrombotic medications  

Additional attention must be given to the arterial puncture site, with longer manual pressure applied after sheath removal, appropriate use of an arterial closure device, or planning of alternative vascular (via radial artery) access for [[PCI]].

==Patients with evidence of active bleeding - melena etc==
==Patients with anemia at baseline==
==Patients who are incidentally occult blood positive==
==Patients with pre-exsiting thrombocytopenia==

Causes of acquired [[thrombocytopenia]] include: 
* [[Idiopathic thrombocytopenic purpura|Idiopathic (immune) thrombocytopenic purpura]] ([[ITP]]), 
* [[thrombocytopenia|Medication induced thrombocytopenia]], 
* [[Thrombotic thrombocytopenic purpura]], 
* [[Hemolytic uremic syndrome]], 
* [[Connective tissue disease]], 
* [[Leukemia]], 
* [[Cancer]], 
* [[AIDS]],  
* [[infection|Chronic infections]].

In patients with [[thrombocytopenia]] undergoing elective [[PCI]], if there is time to plan the procedure the underlying disorder should be corrected if necessary. Any disorder listed above has no absolute contraindication to antiplatelet therapy, so the use of [[aspirin]] and [[clopidogrel]] is warranted. <ref> Nurden AT, Nurden P. Inherited disorders of platelets: an update. Curr Opin Hematol 2006; 13: 157–62.</ref> <ref>Arjomand H, Aquilina P, McCormick D. Acute myocardial infarction in a patient with von Willebrand disease: pathogenetic dilemmas and therapeutic challenges. J Invasive Cardiol 2002; 14: 615–18.</ref> <ref>Girolami A, Randi ML, Ruzzon E et al. Myocardial infarction, other arterial thrombosis and invasive coronary procedures, in hemaophilia B: a critical evaluation of reported cases. J Thromb Thrombolysis 2005; 20: 43–6.</ref> <ref>James PR, de Belder AJ, Kenny MW. Successful percutaneous transluminal coronary angioplasty for acute myocardial infarction in von Willebrand’s disease. Haemophilia 2002; 8: 826–7.</ref> <ref>Arora UK, Dhir M, Cintron G et al. Successful multi-vessel percutaneous coronary intervention with bivalirudin in a patient with severe hemophilia A: a case report and review of literature. J Invasive Cardiol 2004; 16: 330–2.</ref>

==Patients on warfarin==

#'''Elective procedures:''' If [[percutaneous coronary intervention]] ([[PCI]]) is an elective procedure, a common approach would be to stop oral anticoagulant 3–4 days prior to procedure, and switch to continuous IV [[unfractionated heparin]] ([[UFH]]) or subcutaneous [[low molecular weight heparin]] ([[LMWH]]). After required treatment, an oral anticoagulant can be restarted 1–2 days after the procedure, and heparin stopped when therapeutic [[INR]] is achieved. <ref>White RH, McKittrick T, Hutchinson R, et al. Temporary discontinuation of warfarin therapy: changes in the international normalized ratio. Ann Intern Med 1995; 122: 40–42.</ref> Antiplatelet therapy should be used as in any other [[PCI]], with [[aspirin]] and [[clopidogrel]]. The use of [[glycoprotein IIb/IIIa inhibitor]]s in elective procedure in patient without [[ACS]] would not be routinely recommended. [[Glycoprotein IIb/IIIa inhibitor]]s would be used depending on the clinical and angiographic criteria, such as: 
#*Presence of intraluminal [[thrombus]] 
#*Residual coronary artery [[dissection]]
#*Suboptimal procedure result. 
#'''Acute coronary syndromes:''' Patients with [[acute coronary syndrome]]s ([[ACS]]), who require urgent or emergent [[percutaneous coronary intervention]], would be managed in essentially the same manner with [[aspirin]], [[clopidogrel]], [[Glycoprotein IIb/IIIa inhibitors]] and intra procedural IV [[unfractionated heparin]] to achieve the desired activated clotting time (ACT). A careful arterial puncture and deploying an arterial closure devices may reduce the possibility of local bleeding, especially if [[INR]] is elevated. Micropuncture technique, and longer local compression than usual (by 25–30 min) after sheath removal are alternative methods to use of closure devices. Although administration of [[vitamin K]] can reduce the [[INR]] to normal level, this would take at least 6 hours. If required, fresh frozen plasma (FFP) can always be given to manage puncture site related active bleeding.

==Patients with heparin induced thrombocytopenia==

[[Hirudin]], [[argatroban]], and [[bivalirudin]] can be used during [[percutaneous coronary intervention]]s in the setting of [[heparin induced thrombocytopenia]] ([[HIT]]). <ref>Dangas G, Nikolsky E. Commentary: PCI Options in Heparin-Induced Thrombocytopenia. The Journal of Invasive Cardiology - Volume 15 - Issue 11 (Nov 2003), 622-23</ref> Platelet transfusion might be indicated in the case of bleeding or need for emergent [[PCI]] with inadequate [[platelet]] count. [[Aspirin]] and [[clopidogrel]] are not contraindicated in [[heparin induced thrombocytopenia]], and should be used unless the patient has a critically low [[platelet]] count.

A small study with a very slow recruitment rate; '''ATBAT''', the '''A'''nticoagulant '''T'''herapy with '''B'''ivalirudin to '''A'''ssist in the performance of percutaneous coronary intervention in patients with heparin induced '''T'''hrombocytopenia study was an open-labeled prospective study of [[bivalirudin]] in 52 consecutive patients requiring [[PCI]] with [[HIT]] with or without acute thrombosis syndrome. [[Bivalirudin]] was administered in two regimens: ‘high-dose’ standard PCI protocol dose, or 25% decreased bolus with 30% decreased infusion rate. Procedural success rate was 98%. One patient died 46 h after uneventful [[PCI]]. In the whole group there was only 1 case of significant bleeding associated with bypass surgery; and there were 7 cases of minor bleeding. There were no cases of significant [[thrombocytopenia]]. <ref>Mahaffey KW, Lewis BE, Wildermann NM, et al. The Anticoagulant Therapy with Bivalirudin to Assist in the performance of PCI in patients with heparin-Induced Thrombocytopenia (ATBAT) study. J Invas Cardiol 2003; 15: 611-16.</ref> <ref>Fruchter O, Blich M, Jacob G. Fatal acute myocardial infarction during severe thrombocytopenia in a patient with idiopathic thrombocytopenic purpura. Am J Med Sci 2002; 323: 279–80.</ref> <ref>Cochran K, DeMartini TJ, Lewis BE,et al. Use of lepirudin during percutaneous vascular interventions in patients with heparin-induced thrombocytopenia. J Invas Cardiol 2003; 15: 617-21.</ref>

Lewis et al studied [[argatroban]] (25 μg/kg/min (350 μg/kg initial bolus), adjusted to achieve an ACT of 300–450 s) in 91 patients undergoing 112 PCIs.<ref>Lewis BE, Matthai WH, Coehn M, et al., for the ARG-216/310/311 Study Investigators. Argatroban anticoagulation during percutaneous coronary interventions in patients with heparin induced thrombocytopenia. Cathet Cardiovasc Intervent 2002; 57: 177–84.</ref> Of these, 94.5% had a satisfactory outcome of the procedure, and 97.8% achieved adequate anticoagulation. Death (none), myocardial infarction (4 pts), or revascularization (4 pts) at 24 h after PCI occurred in seven (7.7%) patients overall. Only 1 patient (1.1%) experienced periprocedural major bleeding. Overall, [[argatroban]] is a good option in this setting, and is Food and Drug Administration (FDA) approved for this indication. <ref>Matthai WH. Use of argatroban during percutaneous coronary interventions in patients with heparin-induced thrombocytopenia. Semin Thromb Hemost 1999; 25: 57-60.</ref>

==References==
{{Reflist|2}}

==External links==
* [http://www.themdtv.org The MD TV: Comments on Hot Topics, State of the Art Presentations in Cardiovascular Medicine, Expert Reviews on Cardiovascular Research]
* [http://www.clinicaltrialresults.org Clinical Trial Results: An up to dated resource of Cardiovascular Research]

==Additional Readings==

* Common Clinical Dilemmas in Percutaneous Coronary Interventions. Eulógio E Martinez, Pedro A Lemos, Andrew TL Ong, Patrick W Serruys, Taylor & Francis, ISBN 9781841846095


[[Category:Cardiology]]
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