1. Management of Patients on Chronic Oral Anticoagulant Therapy
R. Lee Jobe, MD FACC FSCAI
North Carolina Heart and Vascular
UNC Rex Healthcare
Raleigh, NC

2. R. Lee Jobe, MD FACC FSCAI Medical Advisory Board Boston Scientific
 Financial Disclosures:
Medical Advisory Board
Boston Scientific
Medical Ingenuities

3. Oral Anticoagulant Therapy: Scope of the Issue
Patients with CAD often have comorbid conditions requiring OAC
Atrial Fibrillation
Valvular Heart Disease
Arterial or Venous Thromboembolic Disease
LV or LA thrombus
5-8.5% of patients referred for Cardiac Cath
Femoral Vascular Closure devices do not reduce the risk overall bleeding complications

4. What do the Guidelines Say?
2011 ACC/AHA USA/NSTEMI Wait til INR < 1.5 No preference for access specified 2014 Guidelines silent on OAC 2010 ESC Guidelines Do not interrupt OAC Preference for Radial access

5. Strategies for Management of Oral Anticoagulant Therapy
For low risk patients, stop OAC 4 days prior to procedure, await INR < 1.5
For moderate/high risk patients, stop OAC and bridge with UFH or LMWH when INR < 2, perform cath when INR < 1.5, then resume OAC with bridge
Perform catheterization from radial approach with uninterrupted OAC

6. Among Patients on Home Warfarin Therapy
OAC Delays Guideline Indicated Therapies for NSTEMI ACTION-GWTG
Variable
No Home Warfarin (n=62 061)
Home Warfarin (n=5787)
Among Patients on Home Warfarin Therapy
INR <2.0 (n=2680)
INR = 2.0–3.0 (n = 2006)
INR >3.0 (n = 1101) P*
    Diagnostic cath
89.8
81.5
84.6
81.0
73.2
<0.0001
    Cath within 48 h
74.4
48.4
61.0
40.2
27.1
PCI
54.0
43.0
42.9
45.3
38.4
0.02
PCI within 48 h
45.6
26.4
31.5
24.1
15.4
    Arrival to cath, h§
21.0
43.3
28.8
51.1
66.4
Subherwal et al. Circulation. 2012;125:

7. Advantages of performing TRI on uninterrupted OAC has been long known

8. Comparison of Radial vs Femoral Cath/PCI on warfarin
Transfusion % vs 0%, p=0.004
Any Vascular or
Bleeding Comp % vs 1%, p=0.001
Baker et al. Am Heart J 2014; 168 (4):

9. Advantages of Uninterrupted OAC
Avoid lengthy hospitalization for bridging
Avoid risk of thromboembolism off OAC
Reduce risk of vascular complication by avoiding femoral artery access
Reduced costs by reducing LOS and complication management

10. Special Considerations: If the INR is therapeutic (or NOAC is on board), do we still need to use routine anticoagulation for catheterization or PCI?

11. Radial cardiac catheterization
Purpose of heparin is to prevent radial artery occlusion
Appropriate dose varies u/kg
Does warfarin provide the same protection?

12. Frequency of Radial Artery Occlusion after Transradial Access in Patients Receiving Warfarin
Even if INR is therapeutic, procedural heparin
is required to prevent RAO
Pancholy et al, Am J Cardiol. 2014;113(2):

13. Strategies to Reduce Radial Artery Occlusion
Use lowest profile sheath or sheathless guide possible
Careful adherence to patent hemostasis technique
Administer anticoagulation with heparin even if INR is therapeutic

14. (Sort of a moot point, but…) In Patients on OAC, Is Heparin Required for Transradial PCI?
When TR stenting was first reported, patients on OAC routinely received 10K IU heparin, and sheath pulled immediately post regardless of ACT
Other non-TRI trials have shown that warfarin and ASA is inadequate to prevent stent thrombosis

15. ISAR 1997 Coumarin+ASA Vs Ticlopidine+ASA
Incidence of adverse cardiac events (top) and stent vessel occlusion (bottom) in the three risk groups, differentiating the two antithrombotic regimens: anticoagulant and antiplatelet therapy.
ISAR 1997
Coumarin+ASA Vs
Ticlopidine+ASA
Incidence of adverse cardiac events (top) and stent vessel occlusion (bottom) in the three risk groups, differentiating the two antithrombotic regimens: anticoagulant and antiplatelet therapy.
Helmut Schühlen et al. Circulation. 1997;95:
Copyright © American Heart Association, Inc. All rights reserved.

16. Conclusions Continuing OAC with warfarin when using radial approach for cath and PCI
Safe
Lower risk of bleeding and vascular complictions
Reduced risk of thromboembolic complications from interrupting OAC
Reduced LOS
Reduced costs from complication management and LOS