Monitoring and Reversal of Anticoagulation and Antiplatelet Agents
Optimal inhibition of platelet and coagulation pathways is essential for maximizing antithrombotic effects and minimizing bleeding risk and is critically dependent on individual patient risk. Since some of these agents exhibit variable pharmacokinetic and pharmacodynamic responses, monitoring and reversal strategies are essential to reduce excessive risk of thrombosis and bleeding in selected patients. With respect to antiplatelet agents, monitoring aspirin and glycoprotein IIB/IIa receptor inhibitors are not recommended since the latter agents are associated with uniform and significant inhibition of their targets. Since response to clopidogrel is widely variable and high platelet reactivity during clopidogrel therapy is associated with increased post-stenting ischemic events, platelet function monitoring during clopidogrel therapy and treatment with potent P2Y12 receptor blockers such as prasugrel or ticagrelor have been suggested. Similarly, uniform use of prasugrel and ticagrelor is associated with higher bleeding events, de-escalation of these agents with clopidogrel based on platelet function testing has been shown to improve net clinical benefits. Various methods to monitor anticoagulant agents and reversal agents during percutaneous coronary intervention have been studied and incorporated in routine practice. Direct oral anticoagulants (DOACs) are being increasingly used in interventional cardiology in recent years particularly in patients with atrial fibrillation and heart failure undergoing interventions. Therefore, monitoring and reversal of DOACs have been studied and are addressed in detail in the recent expert consensus documents.
