ABC | Volume 113, Nº1, July 2019

Statement Statement on Antiplatelet Agents and Anticoagulants in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(1):111-134 anticoagulation or PCI should be performed early or not. Once more, when the risk of ischemia is very high, PCI should be performed early, while still under the effect of the medication. The procedure should be postponed, however, whenever the risk of ischemia permits. For patients with creatinine clearance > 50 mL/min, the full effect of NOAC may be considered reversed 24 hours after the last dose. For patients with creatinine clearance, on the other hand, between 30 and 50 mL/min, 48 hours are necessary. Following this period, the patient may thus theoretically undergo PCI with a lower risk of bleeding. Parenteral anticoagulation may be performed in the event that PCI is early, regardless of when the last dose of NOAC was administered. 7,8 In all OAC patients, priority vascular access should always be radial, and femoral access should only be performed in exceptional cases. The use of pre-PCI dual antiplatelet therapy should be routinely avoided in this group of patients. Clopidogrel should only be used once coronary anatomy has been defined and coronary angioplasty with stent placement has been indicated. The use of prasugrel or ticagrelor is contraindicated in this situation, as there is insufficient evidence for their safety in this context. Acetylsalicylic acid (ASA) should always be used at a minimum dose, preferably less than 100 mg daily. 7,8 The use of proton pump inhibitors as prophylaxis against stress ulcers in this group of patients should be the first choice considered due to the elevated risk of gastrointestinal bleeding. 7,8 2.3. Choosing Stent Type for Percutaneous Coronary Intervention The choice of stent type (between the newest generation of drug-eluting stents and conventional stents) in patients who require full anticoagulation continues to generate discussion. Results of the Dual Antiplatelet Therapy (DAPT) study (see section 2.2) showed that the benefits of prolonged dual antiplatelet therapy do not depend on the type of stent used and that the risk of coronary events in patients who suspend therapy due to the need for non-cardiac surgery was the same with either drug-eluting or conventional stents. 9-11 Furthermore, two randomized studies have demonstrated that second-generation drug-eluting stents are superior to conventional stents in patients with high bleeding risks who were not able to tolerate the use of prolonged dual antiplatelet therapy. 12,13 In this manner, stent choice should be individualized based on coronary anatomy and bleeding risk. There are, however, no reasons to contraindicate the use of drug-eluting stents in this group of patients. 2.4. Long-term Antithrombotic Therapy following Percutaneous Coronary Intervention The first instances of evidence on this topic have begun to be published during the last five years, which means that the subject continues to be controversial and to produce doubts. In 2012, data from the DANISH registry in patients with AF and acute myocardial infarction (AMI) showed that the 90-day risk of bleeding significantly increased with the use of triple therapy in comparison with anticoagulation combined with only one antiplatelet agent (hazard ratio [HR] = 1.47, 95% CI 1.04 to 2.08) with no differences in ischemic event rates (HR = 1.15, 95% CI 0.95 to 1.40). In this manner, analysis of this observational study would not recommend routine use of triple therapy. 14,15 The What is the Optimal antiplatElet and anticoagulant therapy in patients with oral anticoagulation and coronary StenTing (WOEST) study, with 573 patients, was the first randomized prospective study published on this topic. All patients were indicated for OAC (69% for AF) and PCI. Patients were divided into 2 groups: warfarin and clopidogrel; and warfarin, clopidogrel, and ASA 80 mg daily. This treatment regimen was maintained for 30 days for conventional stents and 12 months for drug-eluting stents. The primary outcome was any bleeding episode according to TIMI criteria. After 1 one year, they observed a significant reduction in bleeding in the dual therapy group (19.5% versus 44.9%; HR = 0.36, 95% CI 0.26 to 0.50, p < 0.001). There was no different in rates of major bleeding, AMI, stent thrombosis, or stroke. Lower mortality, however, was observed in the dual therapy group (2.5% versus 6.4%, p = 0.027). 16 In 2015, the Triple Therapy in Patients on Oral Anticoagulation after Drug Eluting Stent Implantation (ISAR- TRIPLE) multicenter randomized study, with 614 patients, conducted in Germany and Denmark, evaluated whether shortening the duration of clopidogrel therapy from 6 months to 6 weeks after drug-eluting stent implantation would be associated with superior net clinical outcome in patients receiving aspirin and warfarin concomitantly. They included patients who had been receiving oral anticoagulants for AF for at least 12 months and who had received a drug-eluting stent for stable angina or acute coronary syndrome (ACS). The primary outcomes were death, AMI, stent thrombosis, stroke, and major bleeding in 9 months. No differences were observed in relation to the primary outcomes between the 2 groups (9.8% versus 8.8%; HR = 1.14, 95% CI 0.68 to 1.91; p = 0.63). On the other hand, the incidence of minor bleeding events was higher in the group that used clopidogrel for 6 months (10.9% versus 7.3%, p = 0.03). 17 With respect to NOAC, the PIONEER AF-PCI randomized prospective study evaluated the best pharmacological treatment strategy using rivaroxaban in patients who required OAC due to AF and who were undergoing PCI. The study included 2,124 patients, divided into 3 groups: rivaroxaban (15 mg) + P2Y 12 inhibitor for 12 months; rivaroxaban (2.5 mg twice daily) + ASA + P2Y 12 inhibitor for 1, 6, and 12 months; and warfarin + ASA + P2Y 12 inhibitor for 1, 6, and 12 months. Approximately 93% of patients used clopidogrel as the antiplatelet of choice, and 65% received drug-eluting stent implantation. Approximately 50% of cases had ACS. The primary outcome evaluated was clinically relevant bleeding according to TIMI criteria. They observed bleeding rates of 16.8%, 18.0%, and 26.7%, respectively between the groups (p < 0.001). The rates of mortality, stroke, and cardiovascular events did not show any significant differences. For patients with AF who need stent angioplasty, the authors concluded that dual therapy or triple therapy strategies with reduced doses of 115