Table 4.
Recommendation for managing patients who require oral anticoagulation undergoing percutaneous coronary intervention
| Indications | Grade of recommendation | Level of evidence |
|---|---|---|
| The CHA2DS2-VASc score should be used to evaluate the need for maintaining anticoagulation, and the HAS-BLED score should be used to calculate the risk of bleeding | IIa | C |
| During PCI, priority vascular access should always be radial, and femoral access should only be performed in exceptional cases. | IIa | C |
| Triple therapy should be considered for the shortest time possible, due to the high associated risk of hemorrhage. | IIa | C |
| Utilization of NOAC should be given preference over warfarin, due to the predictability of their effect. | IIa | C |
| When opting to use warfarin, INR should be maintained close to 2.0. | IIa | C |
| Clopidogrel should only be used once coronary anatomy has been defined and coronary angioplasty with stent placement has been indicated, and routine pre-PCI administration should be avoided. | IIa | C |
| The use of prasugrel or ticagrelor is contraindicated in this situation. | III | C |
| ASA should always be used at a minimum dose, preferably ≤ 100 mg daily. | IIa | C |
| 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. | IIa | C |
| Triple therapy should be considered for patients with low hemorrhage risks during the shortest time possible (preferably 1 month, with the possibility of extending up to 6 months). After this period, anticoagulant use in combination with just one antiplatelet agent should be maintained. | IIa | B |
| When there is a high ischemia risk as well as a high hemorrhage risk, the recommendation is to use triple therapy for, at most, 1 month or to begin dual therapy with an anticoagulant and clopidogrel directly. | IIa | B |
| In patients with high risks of bleeding and low ischemia risks, dual therapy with an anticoagulant and clopidogrel should be initiated from the beginning. | IIa | A |
| When opting to use NOAC, the combination of dual therapy with clopidogrel 75 mg daily and rivaroxaban 15 mg daily or dabigatran 110 mg twice daily should be the first choice. | IIb | B |
| Discontinuation of antiplatelet therapy should be considered after 12 months. | IIa | B |
ASA: acetylsalicylic acid; INR: international normalized ratio; NOAC: new oral anticoagulant; PCI: percutaneous coronary intervention.