Safety and efficacy of dual antiplatelet therapy after percutaneous coronary interventions in patients with end-stage liver disease

Abstract

The prevalence of coronary artery disease (CAD) increases in patients with end-stage liver disease, with part of them receiving the percutaneous coronary intervention (PCI) as a treatment option. Dual antiplatelet therapy (DAPT), a standard of care after PCI, could result in catastrophic consequences in this population. Before PCI and the start of DAPT, it is recommended to assess patient bleeding risk. Based on novel findings, liver cirrhosis does not necessarily lead to a significant increase in bleeding complications. Furthermore, conventional methods, such as the international normalized ratio, might not be appropriate in assessing individual bleeding risk. The highest bleeding risk among cirrhotic patients has a subgroup with severe thrombocytopenia (< 50 × 10⁹/L) and elevated portal pressure. Therefore, every effort should be made to maintain thrombocyte count above > 50 × 10⁹/L and prevent variceal bleeding. There is no solid evidence for DAPT in patients with cirrhosis. However, randomized trials investigating short (one month) DAPT duration after PCI with new drug-eluting stents (DES) in a high bleeding risk patient population can be implemented in patients with cirrhosis. Based on retrospective studies (with older stents and protocols), PCI and DAPT appear to be safe but with a higher risk of bleeding complications with longer DAPT usage. Finally, novel methods in assessing CAD severity should be performed to avoid unnecessary PCI and potential risks associated with DAPT. When indicated, PCI should be performed over radial artery using contemporary DES. Complementary medical therapy, such as proton pump inhibitors and beta-blockers, should be prescribed for lower bleeding risk patients. Novel approaches, such as thromboelastography and “preventive” upper endoscopies in PCI circumstances, warn clinical confirmation.

Keywords: End-stage liver disease; Cirrhosis; Liver transplantation; Coronary artery disease; Percutaneous coronary intervention; Antiplatelet therapy

Core Tip: Dual antiplatelet therapy (DAPT) is necessary after a percutaneous coronary intervention (PCI). However, it could result in severe consequences in patients with liver cirrhosis. Based on novel findings, liver cirrhosis does not necessarily lead to a significant increase in bleeding complications. Patients with cirrhosis who have the highest bleeding risk are those with severe thrombocytopenia and elevated portal pressure. Despite the lack of solid evidence for DAPT in patients with cirrhosis, trials investigating one month of DAPT duration after PCI can be implemented in cirrhotic patients. Before PCI, functional assessment of coronary artery disease severity should be performed to avoid unnecessary interventions.