Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 50

Warfarin, per se, is protective against coronary events.^148,149 If a conservative strategy is selected and the patient is appropriately anticoagulated, it may be reasonable to continue warfarin along with other therapies and withhold from adding any other anticoagulant. There is no reason to believe that combining two anticoagulants reduces ischemic events. In fact, overlapping two anticoagulants worsened the bleeding risk in the SYNERGY trial.

Warfarin management in transfemoral catheterization- Warfarin may be held for a few days before the coronary angiogram and a short-acting anticoagulant used instead of warfarin before and during the procedure. This way, the anticoagulation can be stopped after the procedure, reducing the bleeding complications and allowing for the removal of the arterial sheath. Heparin is started as soon as INR<2. The angiogram may be performed transfemorally when the INR is ≤ 1.6. Warfarin is restarted the evening of the procedure, and heparin may be restarted along with warfarin until INR is ≥ 2, because an early procoagulant effect occurs upon warfarin re-initiation and may not be tolerated post ACS. Anticoagulation with heparin at a low PTT target (~1.5× normal) may generally be resumed 12 hours after sheath removal. Avoid LMWH in those patients with a recent femoral access: LMWH is associated with a higher bleeding risk than controlled-dose heparin (SYNERGY trial), and should a bleeding occur, the prolonged effect of LMWH makes it difficult to control.

Warfarin management in transradial catheterization- Warfarin therapy is not interrupted (class IIa ESC), or only one dose is withheld. If PCI is performed, UFH is administered and adjusted according to ACT (UFH is mainly required if INR<2.5, per ESC).

NOAC management- NOAC may be continued around a transradial procedure without any interruption (class IIa ESC), and UFH is administered during PCI. For transfemoral procedures, hold NOAC for 1-2 days.