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Changing roles of anticoagulant and antiplatelet treatment during percutaneous coronary intervention
  1. R V Kelly1,
  2. S Steinhubl2
  1. 1Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, USA
  2. 2University of Kentucky, Lexington, Kentucky, USA
  1. Correspondence to:
    Robert V Kelly MD
    Division of Cardiology, University of North Carolina, Cardiac Catheterization Laboratory, 100 Manning Drive, Chapel Hill, NC, 27514–7075, USA;

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In the development of percutaneous intervention, Dotter first used unfractionated heparin (UFH) alone when performing peripheral angioplasty.1 In the 1970s Gruentzig added 1 g of aspirin (ASA) for three days in coronary angioplasty, which was started the day before the procedure.2 Over the ensuing years empiric attempts were made to improve patient outcomes using dextran and dipyridamole but without success. More recently, along with ASA and UFH, direct thrombin inhibitors, low molecular weight heparin (LMWH), warfarin, fibrinolytics, thienopyridines, and platelet glycoprotein (Gp) IIb/IIIa antagonists have all been studied in efforts to reduce the thrombotic complications associated with a percutaneous coronary intervention (PCI).

Of the multiple combinations of antithrombotic agents that have been tried and tested, only several have been unequivocally proven to be beneficial in placebo controlled trials. A number of others continue to be studied or have persisted empirically. ASA, thienopyridines, UFH, LMWH, direct thrombin inhibitors, and Gp IIb/IIIa antagonists are currently the most commonly utilised antithrombotic agents. As a result of improvements in the antithrombotic regimen, in conjunction with improvements in equipment and technique, the incidence of periprocedural major adverse cardiac events (MACE) and major bleeding have continued to improve.



Aspirin (acetylsalicylic acid, ASA) has been available for over a century yet its cardiac and vascular benefits have only been realised in the last 50 years. The benefit of ASA as antiplatelet treatment in PCI is frequently under-appreciated, but has been well established in short and long term placebo controlled studies. Schwartz showed that the addition of aspirin to heparin in PCI was associated with a 77% relative risk reduction in MACE (p  =  0.013).3 Similarly, White showed that aspirin when combined with heparin was associated with a 75% reduction in MACE (p < 0.001) compared to heparin alone.4 A longer duration of aspirin …

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