Author + information
- Daniel Woronow, MD∗ ()
- ↵∗Division of Cardiology, Holy Cross Hospital, 1400 Forest Glen Road, #215, Silver Spring, Maryland 20910-1468
I read with great interest Dr. Singh's state-of-the-art review entitled “Bleeding Avoidance Strategies During Percutaneous Coronary Interventions” (1). As he points out, the HEAT-PPCI (Unfractionated Heparin Versus Bivalirudin in Primary Percutaneous Coronary Intervention) trial (2) has renewed interest in heparin monotherapy with pre-loading of dual antiplatelet therapy during percutaneous coronary interventions (PCIs). Protamine reversal of heparin anticoagulation can also be considered as a bleeding management and/or bleeding avoidance strategy. Nonetheless, protamine may be underutilized because of concerns regarding possible heparin rebound, cardiac and peripheral thrombotic effects, and the potential for allergic or anaphylactic reactions. Protamine-related adverse events occur in ∼2.6% of treated patients but may be as high as 11% with a less restrictive definition (3). Briguori et al. (4) previously concluded that patients who received protamine to reverse heparin-associated bleeding complications after coronary stent implantation did not sustain higher rates of stent thrombosis compared with similar nonprotamine-treated patients. Protamine is generally well tolerated when routinely used at the conclusion of cardiopulmonary bypass procedures in patients with cardiovascular clinical characteristics similar to patients undergoing PCI. Meta-analysis of routine utilization of protamine for the reversal of heparin anticoagulation post-PCI has shown favorable results in properly selected patients (5).
Interventionalists may consider protamine reversal of heparin anticoagulation as a reasonable strategy for the treatment of significant post-procedural bleeding events. Further clinical studies are appropriate to define the optimal role of protamine post-femoral access PCI, to reverse heparin anticoagulation, and to potentially avoid PCI-associated bleeding events in patients who have also undergone appropriate pre-loading with dual antiplatelet therapy.
Please note: Dr. Woronow has reported that he has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Singh M.
- Kimmel S.,
- Sekeres M.,
- Berlin J.,
- et al.