Is a Direct Oral Anticoagulant (DOAC) indicated post Percutaneous Coronary Intervention (PCI) with stenting?

DOAC Use After PCI with Stenting

In patients with an indication for oral anticoagulation who undergo PCI with stenting, a DOAC (unless contraindicated) is recommended in preference to vitamin K antagonists (VKA) as part of the antithrombotic regimen. 1

Antithrombotic Strategy After PCI with Stenting

The optimal antithrombotic regimen depends on whether the patient has an indication for oral anticoagulation:

For Patients WITHOUT an Indication for Oral Anticoagulation:

• Dual antiplatelet therapy (DAPT) consisting of aspirin 75-100 mg and clopidogrel 75 mg daily for up to 6 months is the default strategy 1
• In patients at high bleeding risk but not at high ischemic risk, discontinue DAPT after 1-3 months and continue with single antiplatelet therapy 1

For Patients WITH an Indication for Oral Anticoagulation (e.g., AF):

1. Initial therapy: Low-dose aspirin (loading dose when not on maintenance dose) plus OAC and clopidogrel 1
2. Subsequent therapy:
   • Early cessation of aspirin (≤1 week)
   • Continue OAC and clopidogrel:
     • For 6 months in patients not at high ischemic risk
     • For 12 months in patients at high ischemic risk
   • Then OAC alone thereafter 1

DOAC vs. VKA After PCI with Stenting

DOACs are preferred over VKAs in this setting due to:

• Reduced bleeding risk: Meta-analyses show DOACs reduce major bleeding by 34% compared to VKA-based regimens 2
• Equivalent efficacy: No significant difference in cardiac ischemic events, stroke, or mortality between DOACs and VKAs 2

Important Considerations

Dose Adjustments

When concerns about high bleeding risk prevail:

• Rivaroxaban 15 mg daily should be considered instead of 20 mg daily during antiplatelet therapy 1
• Dabigatran 110 mg twice daily should be considered instead of 150 mg twice daily during antiplatelet therapy 1

Contraindications

• Ticagrelor or prasugrel are generally not recommended as part of triple antithrombotic therapy with aspirin and OAC 1
• Triple therapy (OAC + DAPT) should be limited to the shortest duration possible to minimize bleeding risk 1

Bleeding Prevention

• A proton pump inhibitor is recommended in patients at increased risk of gastrointestinal bleeding for the duration of combined antithrombotic therapy 1
• Consider radial access for PCI to minimize bleeding risk 1

Common Pitfalls to Avoid

1. Prolonged triple therapy: Extended triple therapy significantly increases bleeding risk without clear ischemic benefit
2. Underdosing anticoagulation: Despite bleeding concerns, ensure appropriate therapeutic dosing of DOACs
3. Overlooking drug interactions: Be aware of potential interactions between antiplatelet agents and anticoagulants
4. Failing to reassess: Regularly reevaluate the need for continued antiplatelet therapy alongside anticoagulation

The evidence strongly supports using DOACs over VKAs when oral anticoagulation is indicated after PCI with stenting, with a strategy that minimizes the duration of triple therapy to reduce bleeding complications while maintaining protection against thrombotic events.