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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 1, January/February 2021
AFRICA
3
Can we reduce bleeding risk after interventional
procedures?
Farrel Hellig
Clinical and interventional cardiology has made a huge positive
impact on the lives of cardiac patients. Many patients have
improved quality of life, increased longevity and fewer major
clinical events such as myocardial infarction or stroke.
An important component of therapies for heart disease
is the use of anticoagulants and/or antiplatelet medications.
However, in some individuals, these therapies, prescribed with
the purpose of improved patient outcome, have the very opposite
effect as they promote bleeding, a major side effect of modern
cardiovascular medicine.
While guidelines help us to make choices based on balancing
the risks of thrombosis and bleeding, individual cases may require
a unique tailored approach based on their personal clinical
profile and their history. One of the greatest clinical challenges
for the modern cardiologist is bleeding in a patient who needs
anticoagulation or antiplatelet drugs. This is particularly true
when the clinical scenario makes discontinuation of such therapy
dangerous, while bleeding is itself life threatening. Bleeding
increases the mortality rate
1-4
and therefore bleeding prevention
or creating an environment where it is safer to discontinue drugs
if bleeding occurs is a goal worth striving for.
In this edition of the journal are two publications that deal
with the issue of bleeding mitigation in two different scenarios
where such medications are used in standard practice. The first
publication, Abelson
et al
.,
5
reflects on the nine-year, single-centre
experience of left atrial appendage occlusion (LAAO), a technique
designed to eliminate the need for anticoagulation in patients
with atrial fibrillation (AF) who have bled or are at high bleeding
risk. The second article by Vachiat and colleagues
6
focuses on a
methodology in the cathlab, which allows for a reduced period of
dual antiplatelet therapy (DAPT) in patients with symptomatic
complex or diffuse coronary disease with high bleeding risk. This
editorial examines the following: the value of these procedures in
the studied population, the limitations of the publications, and the
placement of these findings in an African context.
In the Abelson article, page 33, the study population had a
mean age of 74 years. Patients were at a high risk of both stroke
and bleeding (CHADS
2
-VASc score 3.9/HAS-BLED score 2.99)
and 71% had previously suffered a major bleed. These are the
typical patients chosen for LAAO in prior clinical studies and
registries and, therefore, LAAO was an appropriate therapeutic
option for these patients.
Patients received dual antiplatelet therapy for one month post
procedure. This is a short duration when compared to regimens
in other studies, and it is reassuring to note that the stroke rate
was not different to studies where the duration was longer. These
patients were treated with LAAO because of their inability to
tolerate anticoagulation, so the shortest possible duration of
post-procedural anticoagulation was ideal. Further study is
required on the optimal post-procedural duration of therapy
and what that therapy should be. Options include warfarin,
direct oral anticoagulants (DOAC), DAPT, single antiplatelet
therapy (aspirin or P2Y12 inhibitor) or zero therapy in very high
bleeding risk cases.
In this study, patients continued on aspirin long term. Many
such patients have another indication for long-term aspirin, such
as coronary disease, but long-term use of aspirin in patients who
do not need aspirin for other reasons is a matter that needs to be
resolved. Aspirin itself carries a significant bleeding risk
7
and is
particularly problematic with regard to gastrointestinal bleeding,
which was the indication for LAAO in the majority of cases in
the dataset. Patients who were on no aspirin at follow up did not
demonstrate increased stroke risk – but these numbers are small
and this requires further randomised investigation.
In the article by Vachiat
et al
.,
6
page 28, of which I am a
co-author, patients with diffuse, calcified coronary artery disease
were treated with DAPT post intervention, but a number of
patients had discontinued DAPT by three months and the
majority by six months. The patients were of the same average
age (74 years) and had similar bleeding risk to those in the
Abelson study. There is increasing emerging data on shorter-
duration DAPT usage post drug-eluting stent (DES), with even
one month of DAPT, followed thereafter by a single antiplatelet
drug after modern DES implantation.
8
However, the types of patients in the Vachiat article displayed
a greater degree of lesion complexity. There were acute coronary
syndrome cases included and stenting in elderly patients (average
74 years and 35% over 80 years) with diffuse disease and
considerable calcification, long lesions [average drug-eluting
balloon (DEB) length 37 mm] and small vessel lumens (mostly
2.5 mm). Such anatomy is associated with more stent under-
expansion, longer and more overlapping stents, as well as smaller
stent usage. Therefore, these cases carry a higher risk of late
stent complications, usually mandating a longer-than-average
duration of DAPT.
Shortening the duration of DAPT in these patients requires
avoidance of stent implantation. Therefore, the strategy of
rotational atherectomy to enhance vessel compliance, followed
by balloon dilatation and then DEB to prevent restenosis is a
logical approach. The procedural success rate was high (100%),
Sunninghill Hospital, Johannesburg; Division of Cardiology,
University of Cape Town, Cape Town, South Africa
Farrel Hellig, BSc, MB BCh, FCP (SA), FSCAI,
drhellig@tickerdoc.co.zaEditorial