Variability in Contemporary Heparin Prescription and Activated Clotting Time Monitoring During Percutaneous Coronary Intervention: Call for Up-To-Date Evidence-Based Guidelines

Omar Al-Mukhtar; Dion Stub; Christopher M Reid; Sidney Lo; Jeffrey Lefkovits; Antony Walton; Derek P Chew; Andy Yong; Stephen J Nicholls; Nicholas Cox; Karlheinz Peter; William Chan

doi:10.1016/j.hlc.2023.09.020

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 Dec;32(12):1475-1481. doi: 10.1016/j.hlc.2023.09.020. Epub 2023 Nov 22.

Authors

Omar Al-Mukhtar¹, Dion Stub², Christopher M Reid³, Sidney Lo⁴, Jeffrey Lefkovits⁵, Antony Walton⁶, Derek P Chew⁷, Andy Yong⁸, Stephen J Nicholls⁷, Nicholas Cox⁹, Karlheinz Peter², William Chan¹⁰

Affiliations

¹ Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Department of Cardiology, Northern Health, Melbourne, Victoria, Australia. Electronic address: http://www.twitter.com/O_AL_MUKHTAR.
² Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Baker Heart and Diabetes Institute, Melbourne, Vic, Australia.
³ 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.
⁴ Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia.
⁵ School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia.
⁶ 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.
⁷ Department of Cardiology (Monash Heart), Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia; Victorian Heart Institute, Melbourne, Vic, Australia.
⁸ Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia.
⁹ Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Melbourne, Vic, Australia.
¹⁰ 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. Electronic address: William.Chan@unimelb.edu.au.

PMID: 37993342
DOI: 10.1016/j.hlc.2023.09.020

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.

Keywords: Activated clotting time; Heparin; Percutaneous coronary intervention.

Copyright © 2023 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

MeSH terms

Anticoagulants / therapeutic use
Cross-Sectional Studies
Heparin*
Humans
Percutaneous Coronary Intervention*
Treatment Outcome

Substances

Heparin
Anticoagulants