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Al-Mukhtar O, Stub D, Reid CM, Lo S, Lefkovits J, Walton A, Chew DP, Yong A, Nicholls SJ, Cox N, Peter K, Chan W. Variability in Contemporary Heparin Prescription and Activated Clotting Time Monitoring During Percutaneous Coronary Intervention: Call for Up-To-Date Evidence-Based Guidelines. Heart Lung Circ 2023; 32:1475-1481. [PMID: 37993342 DOI: 10.1016/j.hlc.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/17/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Unfractionated heparin (UFH) is the preferred anticoagulant agent in percutaneous coronary intervention (PCI) procedures for minimising the risk of thrombotic complications. Because of the narrow therapeutic range of UFH, some society guidelines have advocated the use of the activated clotting time (ACT) test to monitor anticoagulation intensity during PCI to reduce thrombotic and bleeding complications. We aimed to assess the current practice of UFH prescription and its monitoring in Australia and New Zealand (ANZ). METHOD We conducted an anonymous voluntary cross-sectional survey of interventional cardiologists (ICs) who were members of the Cardiac Society of Australia and New Zealand in 2022. The survey included 10 questions pertaining to the current practice of anticoagulation during PCI. RESULTS Of 430 ICs surveyed, 148 responded (response rate, 34.4%). Most ICs (84.4%) prescribed 70-100 IU/kg of UFH for PCI. Over half of ICs (58.7%) routinely measured ACT during PCI, whereas only 22.2% routinely measured ACT after PCI to guide additional UFH prescription. Among ICs who prescribed additional UFH, approximately half (48%) aimed for ACT ≥250 seconds. Factors that influenced post-PCI UFH prescription included vascular access site and concomitant antiplatelet or anticoagulant therapy. CONCLUSIONS The contemporary practice of UFH prescription during PCI and ACT monitoring in ANZ is variable and based on outdated evidence preceding current drug-eluting stents, antiplatelet therapies, and radial-first practice. Current society guideline recommendations lack clarity and agreement, reflecting the quality of the available evidence. Up-to-date clinical trials evaluating UFH prescription and ACT monitoring are needed to optimise clinical outcomes in contemporary PCI procedures.
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Affiliation(s)
- Omar Al-Mukhtar
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia. http://www.twitter.com/O_AL_MUKHTAR
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; National Health and Medical Research Council Centre of Research Excellence in Cardiovascular Outcomes Improvement, Curtin University, Perth, WA, Australia
| | - Sidney Lo
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Derek P Chew
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Melbourne, Vic, Australia
| | - Andy Yong
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia
| | - Stephen J Nicholls
- Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Melbourne, Vic, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia.
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Caroff J, Aubert L, Lavenu-Bombled C, Figueiredo S, Habchi K, Cortese J, Eugene F, Ognard J, Tahon F, Forestier G, Ifergan H, Zhu F, Hak JF, Reyre A, Laubacher M, Traore A, Desilles JP, Derraz I, Moreno R, Bintner M, Charbonnier G, Le Bras A, Veunac L, Gariel F, Redjem H, Sedat J, Tessier G, Dumas V, Gauberti M, Chivot C, Consoli A, Bricout N, Tuilier T, Guedon A, Pop R, Thouant P, Bellanger G, Zannoni R, Soize S, Richter JS, Heck O, Mihalea C, Burel J, Girot JB, Shotar E, Gazzola S, Boulouis G, Kerleroux B. Antithrombotic therapies for neurointerventional surgery: a 2021 French comprehensive national survey. J Neurointerv Surg 2023; 15:402-407. [PMID: 35347058 DOI: 10.1136/neurintsurg-2021-018601] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/15/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neurointerventionists lack guidelines for the use of antithrombotic therapies in their clinical practice; consequently, there is likely to be significant heterogeneity in antithrombotic use between centers. Through a nationwide survey, we aimed to obtain an exhaustive cross-sectional overview of antithrombotic use in neurointerventional procedures in France. METHODS In April 2021, French neurointerventional surgery centers were invited to participate in a nationwide 51-question survey disseminated through an active trainee-led research collaborative network (the JENI-RC). RESULTS All 40 centers answered the survey. Fifty-one percent of centers reported using ticagrelor and 43% used clopidogrel as premedication before intracranial stenting. For flow diversion treatment, dual antiplatelet therapy was maintained for 3 or 6 months in 39% and 53% of centers, respectively, and aspirin was prescribed for 12 months or more than 12 months in 63% and 26% of centers, respectively. For unruptured aneurysms, the most common heparin bolus dose was 50 IU/kg (59%), and only 35% of centers monitored heparin activity for dose adjustment. Tirofiban was used in 64% of centers to treat thromboembolic complications. Fifteen percent of these comprehensive stroke centers reported using tenecteplase to treat acute ischemic strokes. Cangrelor appeared as an emergent drug in specific indications. CONCLUSION This nationwide survey highlights the important heterogeneity in clinical practices across centers. There is a pressing need for trials and guidelines to further evaluate and harmonize antithrombotic regimens in the neurointerventional field.
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Affiliation(s)
- Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Laurent Aubert
- Department of Anesthesia and Surgical Resuscitation Department, Bicetre Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Saclay, Le Kremlin-Bicetre, France
| | - Cécile Lavenu-Bombled
- Department of Biological Hematology, Assistance Publique-Hôpitaux de Paris, Faculté de médecine Paris Saclay, Hospital Bicetre, Le Kremlin-Bicetre, France
| | - Samy Figueiredo
- Department of Anesthesia and Surgical Resuscitation Department, Bicetre Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Saclay, Le Kremlin-Bicetre, France
| | - Kamelia Habchi
- Department of Anesthesia and Surgical Resuscitation Department, Bicetre Hospital, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris Saclay, Le Kremlin-Bicetre, France
| | - Jonathan Cortese
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | | | - Julien Ognard
- Department of Neuroradiology, CHU Brest, Brest, France
| | - Florence Tahon
- Department of Neuroradiology, Hôpital Privé Clairval, Marseille, France
| | | | - Heloise Ifergan
- Diagnostic and Interventional Neuroradiology, CHU Tours, Tours, France
| | - François Zhu
- Department of Diagnostic and Interventional Neuroradiology, CHU Nancy, Nancy, France.,Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | | | - Anthony Reyre
- Department of Neuroradiology, Hospital Timone, Marseille, France
| | | | - Abdoulaye Traore
- Department of Neuroradiology, Hôpital Louis Pasteur, Colmar, France
| | | | - Imad Derraz
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Ricardo Moreno
- Department of Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marc Bintner
- Department of Neuroradiology, CHU de la Réunion, Saint-Denis, France
| | | | - Anthony Le Bras
- Department of Radiology, CH Bretagne Atlantique Site Chubert, Vannes, France
| | - Louis Veunac
- Department of Radiology, CH de la Cote Basque, Bayonne, France
| | - Florent Gariel
- Department of Interventional Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Hocine Redjem
- Department of Interventional Neuroradiology, Clinique des Cèdres, Toulouse, France
| | - Jacques Sedat
- Department of Interventional Neuroradiology, CHU Nice, Nice, France
| | | | - Victor Dumas
- Department of Radiology, CHU Poitiers, Poitiers, France
| | | | - Cyril Chivot
- Department of Neuroradiology, CHU Amiens-Picardie, Amiens, Hauts-de-France, France
| | - Arturo Consoli
- Department of Neuroradiology, Hospital Foch, Suresnes, France
| | - Nicolas Bricout
- Department of Interventional Neuroradiology, CHU Lille, Lille, France
| | - Titien Tuilier
- Department of Neuroradiology, CHU Henri Mondor, Créteil, France
| | - Alexis Guedon
- Department of Neuroradiology, CHU Lariboisiere Fernand-Widal, Paris, France
| | - Raoul Pop
- Department of Neuroradiology, CHU Strasbourg, Strasbourg, France
| | | | | | - Riccardo Zannoni
- Department of Neuroradiology, CHU Saint-Etienne, Saint-Etienne, France
| | | | | | - Olivier Heck
- Department of Neuroradiology, CHU Grenoble, Grenoble, France
| | - Cristian Mihalea
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Julien Burel
- Department of Radiology, CHU Rouen, Rouen, France
| | | | - Eimad Shotar
- Department of Neuroradiology, CHU Pitié Salpêtrière, Paris, France
| | - Sebastian Gazzola
- Department of Neuroradiology, Saint Anne Military Hospital, Toulon, France
| | | | - Basile Kerleroux
- Department of Neuroradiologie, Saint Anne Hospital, Paris, France
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