OBJECTIVE To explore the adjustment strategies for antithrombotic therapy(anticoagulation and antiplatelet agents) led by clinical pharmacists after percutaneous coronary intervention(PCI) in patients with end-stage kidney disease on long-term hemodialysis and atrial fibrillation.

METHODS  Clinical pharmacists participated in the whole-process antithrombotic management of a patient with long-term hemodialysis complicated by atrial fibrillation after PCI. Based on the patient's high bleeding risk(HAS-BLED score of 4) and lower net benefit of anticoagulation(dialysis risk score of 0), the pharmacists suggested a cautious evaluation of the necessity of warfarin anticoagulation; and targeting the patient's clopidogrel genotype resistance and high ischemic risk after PCI, assisted physicians in formulating an individualized antithrombotic regimen.

RESULTS Based on the dialysis risk score and the limitations of current evidence, the pharmacist determined the patient’s net anticoagulation benefit to be marginal and advised rigorous monitoring for warfarin-associated bleeding. Addressing the high post PCI ischemic risk and the clopidogrel intermediate metabolizer phenotype, the pharmacist recommended a strategy of therapeutic dose intensification: increasing the Clopidogrel dose to 150 mg·d⁻¹ temporarily in the immediate post PCI phase to overcome potential platelet resistance. Furthermore, following the principle of balancing ischemic and bleeding risks, a de-escalation of the dose back to the standard level was suggested at the 3-month follow-ups. During the follow-up period, the patient’s antithrombotic regimen achieved a smooth transition, and no major ischemic or hemorrhagic events occurred.

CONCLUSION Clinical pharmacists assisted physicians in developing an individualized antithrombotic strategy for this high-risk patient leveraging their professional expertise. This practice is crucial for enhancing medication safety and efficacy in patients with complex cardiovascular disease requiring hemodialysis.