Does anybody have experience with Dabigatran in this case? After RELY what the opinion of our colleagues about this revolutionary new oral anticoagulan? thanks

In my experience, it is not the combination of Plavix and Coumadin that is problematic, but ASA plus the two aformentioned agents. I routinely perform heart caths on patients with INRs in the 2-3 range without reversing the anticoagulation and the predominant majority of the patients who need to be stented are treated with DES. I categorically avoid ASA in these patients, but instead utilize Pletal. I have been using Pletal as a third agent in all patients who are not on Coumadin, since February of 2004 when Pletal became available in the generic form with excellent results. It is an extension of this practice that I have eliminated ASA in patients who are on Coumadin and who have undergone PCI. Looking at a total of over 1500 interventions during this time period, I have not encountered a single instance of bleeding complications in the patients treated with Coumadin, Plavix and Pletal. The few patients who did not tolerate the Pletal in this subgroup were trreated with Plavix and INR of 2.5-3.5 quite uneventfully.

 As I am certain you are aware, the data on the efficacy of Pletal as an anti-platelet agent is abundant. Unfortunately the studies are all small and as such not guideline altering. Also, given that the drug is generic, it is virtually certain that a guideline altering study will never be performed. This not withstanding, my personal (and hence anectodal) experience with this drug has led me to be an absolute believer it its efficacy as an antiplatelet agent and its safety in not increasing the risk of bleeding. I have used this agent as monotherapy in 5 cases where the patients had undergone DES deployment and had to be taken off ASA and Plavix withing days post PCI due to GI bleeds, or emergent non-cardiac surgery.