Efficacy and safety of oral anticoagulants in patients with atrial fibrillation and acute myocardial infarction: a systematic review and meta-analysis

BACKGROUND

The optimal antithrombotic therapy strategies for patients with atrial fibrillation (AF) and acute myocardial infarction (AMI) remain uncertain. We aimed to evaluate the efficacy and safety of oral anticoagulants (OAC) among patients with AF and AMI.

METHODS

PubMed, Embase, and Web of Science were searched from inception till 5 February 2025. The primary outcome was any stroke.

RESULTS

Eleven studies with 83 549 patients were included. OAC therapy was associated with lower risks of any stroke (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.60-0.77; P < .001), ischemic stroke (OR: 0.64; 95% CI: 0.57-0.73; P < .001), and all-cause mortality (OR: 0.81; 95% CI: 0.74-0.89; P < .001). Additionally, OAC therapy was associated with a higher risk of any bleeding (OR: 1.24; 95% CI: 1.06-1.46; P = .009), but not for major bleeding (OR: 1.28; 95% CI: 0.87-1.90; P = .21).

CONCLUSIONS

OAC therapy is effective for patients with AF and AMI, but should be administered cautiously in those at high bleeding risk.

Oral anticoagulation in patients with left ventricular thrombus: a systematic review and meta-analysis

AIMS

Direct oral anticoagulants (DOACs) are increasingly used off-label to treat patients with left ventricular thrombus (LVT). We analysed available meta-data comparing DOACs and vitamin K antagonists (VKAs) for efficacy and safety.

METHODS

We conducted a systematic search and meta-analysis of observational and randomized data comparing DOACs vs. VKAs in patients with LVT. Endpoints of interest were stroke or systemic embolism, thrombus resolution, all-cause death, and a composite bleeding endpoint. Estimates were pooled using a random-effects model meta-analysis, and their robustness was investigated using sensitivity and influential analyses.

RESULTS

We identified 22 articles (18 observational studies, 4 small randomized clinical trials) reporting on a total of 3587 patients (2489 VKA vs. 1098 DOAC therapy). The pooled estimates for stroke or systemic embolism [odds ratio (OR): 0.81; 95% confidence interval (CI): 0.57, 1.15] and thrombus resolution (OR: 1.12; 95% CI: 0.86, 1.46) were comparable, and there was low heterogeneity overall across the included studies. The use of DOACs was associated with lower odds of all-cause death (OR: 0.65; 95% CI: 0.46, 0.92) and a composite bleeding endpoint (OR: 0.67; 95% CI: 0.47, 0.97). A risk of bias was evident particularly for observational reports, with some publication bias suggested in funnel plots.

CONCLUSION

In this comprehensive analysis of mainly observational data, the use of DOACs was not associated with a significant difference in stroke or systemic embolism, or thrombus resolution, compared with VKA therapy. The use of DOACs was associated with a lower rate of all-cause death and fewer bleeding events. Adequately sized randomized clinical trials are needed to confirm these findings, which could allow a wider adoption of DOACs in patients with LVT.

Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies

Background

Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified.

Objectives

The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy.

Design

The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials.

Setting

The study was set in primary and secondary care in England from 2010 to 2017.

Participants

Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome.

Data sources

Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics.

Interventions

Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor.

Main outcome measures

Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events.

Results

The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195).

Conclusions

This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy.

Limitations

The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted.

Future work

Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions.

Trial registration

This trial is registered as ISRCTN76607611.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.

Antiplatelet therapy indication in patients also prescribed direct oral anticoagulants

Direct oral anticoagulants (DOACs) are standard of care for venous thromboembolism (VTE) treatment and stroke prevention in atrial fibrillation (AF). Adding antiplatelet therapy (APT) to an oral anticoagulant (OAC) causes a 2-fold increase in major bleeding. As such, recent guidelines recommend limiting the duration and indication of combined therapy in patients already on an OAC. Despite these recommendations, approximately one-third of anticoagulated patients are prescribed concomitant APT. University of Utah Health patients receiving DOAC + APT between August 1, 2019 and November 30, 2019 were included. These were categorized into four groups by APT indication: primary atherosclerotic cardiovascular disease (ASCVD) prevention, ASCVD-no percutaneous coronary intervention (PCI), ASCVD-PCI ≤ 12 months prior, ASCVD-PCI > 12 months prior. The primary outcome was the proportion of DOAC patients receiving concomitant APT for each indication. During the study period, 347 patients received DOAC + APT, primarily for AF (59.1%) or VTE (33.1%), and the most common DOAC was apixaban (76.7%).The most common indication for APT was ASCVD-no PCI (47.3%), followed by ASCVD-PCI > 12 months prior (30.8%), primary ASCVD prevention (18.7%), and ASCVD-PCI ≤ 12 months prior (1.7%). Five patients (1.4%) were on APT with unclear indication. Based on recent guidelines limiting indications and duration of APT added to anticoagulation, over 95% of patients in this single-center study warranted re-assessment of APT indication, with stable ASCVD and primary prevention being prime targets for APT de-prescribing. This study highlights the tremendous potential to improve patient safety and reduce bleeding harm.

Oral anticoagulant therapy for patients with new-onset atrial fibrillation following acute myocardial infarction: A narrative review

Background

To evaluate the advantages and disadvantages of anticoagulant therapy and provide a piece of information on anti-thrombotic treatment strategies for patients with new-onset atrial fibrillation (NOAF) and acute myocardial infarction (AMI).

Methods

Literature from PubMed and Google scholar were screened until August 2022. Studies assessing oral anticoagulant (OAC) treatments for NOAF in patients with AMI were evaluated for inclusion.

Results

Three retrospective cohort studies were included. In the study performed by Madsen et al., patients with previously diagnosed AMI with or without NOAF were followed up for 5.8 years. About 38% of NOAF patients with anticoagulant therapies, which could reduce long-term mortality [adjusted hazard ratio (HR): 0.69; 95% confidence interval (CI): 0.47–1.00]. Hofer et al. performed a single-center cohort study containing 1,372 patients with AMI with an 8.6-year follow-up period. Dual anti-thrombotic therapy (DAT) did not show the effect on the survival in NOAF (adjusted HR: 0.97; 95% CI: 0.65–1.57), while triple antithrombotic therapy (TAT) could reduce long-term cardiovascular mortality (adjusted HR: 0.86; 95% CI: 0.45–0.92). Petersen et al. also did a cohort study with 1-year follow-up duration. It showed that anticoagulant therapies demonstrated positive results (HR: 0.78; 95% CI: 0.41–1.47).

Conclusion

Recent studies have shown that anticoagulant therapy in AMI-NOAF patients can obviously reduce the mortality of AMI-NOAF patients, especially OAC therapy. Further clinical trials could confirm these findings.

Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention

Patients with atrial fibrillation (AF) are at increased risk for coronary artery disease (CAD). After percutaneous coronary intervention (PCI), the antithrombotic therapy consists of a combination of anticoagulant and antiplatelet agents to reduce the ischemic and thromboembolic risk, at the cost of increased bleeding events. In the past few years, several randomized clinical trials involving over 12,000 patients have been conducted to compare the safety of vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs) in association with a single- or double-antiplatelet agent, in the so-called dual- (DAT) or triple-antithrombotic therapy (TAT). These studies and several meta-analyses showed a consistent benefit for reducing bleeding events of DAT over TAT and of DOAC over VKA, without concerns about ischemic endpoints, except for a trend for increased stent thrombosis risk. The present paper examines current international guidelines’ recommendations and reviews clinical trials, meta-analyses, and observational studies conducted on AF patients treated with DAT or TAT after PCI for acute coronary syndromes.

Atrial fibrillation incidence, prevalence, predictors, and adverse outcomes in acute coronary syndromes: A pooled analysis of data from 8 million patients

OBJECTIVE

To summarize data on the prevalence/incidence, risk factors and prognosis of atrial fibrillation (AF) in patients with acute coronary syndromes (ACS).

METHODS

MEDLINE, Embase, and Web of Science were searched to identify all published studies providing relevant data through August 23, 2020. Random-effects meta-analysis method was used to pool estimates.

RESULTS

We included 109 studies reporting data from a pooled population of 8 239 364 patients. The prevalence rates were 5.8% for pre-existing AF, 7.3% for newly diagnosed AF, and 11.3% for prevalent (total) AF, in patients with ACS. Predictors of newly diagnosed AF included age (per year increase) (adjusted odds ratio [aOR]: 1.05), C-reactive protein (aOR: 1.49), left atrial (LA) diameter (aOR: 1.08), LA dilatation (aOR: 2.32), left ventricular ejection fraction <40% (aOR: 1.82), hypertension (aOR: 1.87), and Killip ˃ 1 (aOR: 1.85), p < .01 in all analyzes. Newly diagnosed AF was associated with an increased risk of acute heart failure (adjusted hazard ratio [aHR]: 3.20), acute kidney injury (aHR: 3.09), re-infarction (aHR: 1.96), stroke (aHR: 2.15), major bleeding (aHR: 2.93), and mortality (aHR: 1.80) in the short term; and with an increased risk of heart failure (aHR: 2.21), stroke (aHR: 1.75), mortality (aHR: 1.67), CV mortality (aHR: 2.09), sudden cardiac death (aHR: 1.53), and a composite of major adverse cardiovascular events (aHR: 1.54) in the long term (beyond 1 month), p < .05 in all analyzes.

CONCLUSION

One in nine patients with ACS has AF, with a high proportion of newly diagnosed AF. AF, in particular newly diagnosed AF, is associated with poor short-term and long-term outcomes in patients with ACS.

Efficacy and Safety Outcomes of Short Duration Antiplatelet Therapy with Early Cessation of Aspirin Post Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

BACKGROUND

The optimal duration of dual antiplatelet therapy is a matter of ongoing research. Clinical studies are assessing the optimal duration with the most favourable risk to benefit ratio. The efficacy of P2Y12 receptor inhibitors comparable to aspirin in preventing recurrent ischaemic events in patients with coronary artery diseases.

OBJECTIVES

To investigate the outcomes of short-duration dual antiplatelet therapy after PCI with early discontinuation of aspirin while maintaining patients on P2Y12 inhibitor through systematic review and meta-analysis of available literature.

METHODS

We systematically searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov. We included randomized controlled studies that measured clinical outcomes of efficacy (mortality and ischaemic events) and safety (bleeding) of short and standard-duration dual antiplatelet therapy. The protocol of this study was registered in the international prospective register of systematic reviews PROSPERO registry (CRD42020171468).

RESULTS

Four randomized controlled trials were included; GLOBAL LEADERS, SMARTCHOICE, STOPDAPT-2, and TWILIGHT. The total number of patients was 29,089. The safety outcomes showed a significant reduction in major bleeding events with short-duration dual antiplatelet therapy; the risk ratio was 0.61 (95% CI 0.38-0.99; z=2,00, p=0.05). There was no difference between short and standard-duration dual antiplatelet therapy regarding efficacy outcomes (all- cause death, major adverse cardiovascular events, myocardial infarction, stroke, and stent thrombosis).

CONCLUSION

Short-duration dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy after PCI is a feasible option and can be adopted, especially in patients with a high risk of bleeding.

Relationship between predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score and mortality among patients with atrial fibrillation undergoing percutaneous coronary intervention

BACKGROUND

The predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy, PRECISE-DAPT (P-DAPT) score has been validated in large cohorts as an effective tool in predicting bleeding complication after dual antiplatelet therapy (DAPT) as well as in predicting in-hospital mortality. The implication of using this score to predict outcomes, including mortality in patients with atrial fibrillation (AF) undergoing PCI is unknown.

OBJECTIVE

Role of P-DAPT score to study clinical outcomes, including mortality, hospitalization, and major bleeding, particularly among patients with AF.

METHODS

This is a retrospective observational study of 18,850 consecutive patients who underwent percutaneous coronary intervention (PCI) across a large multihospital healthcare system from 2010 to 2019. Patients were stratified into four groups depending on the presence or absence of AF and P-DAPT score, with score ≥ 25 defined as high risk. The primary outcome was all-cause mortality. The secondary outcomes evaluated were hospitalization and major bleeding.

RESULTS

In the unadjusted analyses, a P-DAPT score ≥ 25, in both AF and non-AF population, was associated with increased mortality, hospitalization, and bleeding. After adjusting for baseline covariates, no significant differences in major bleeding risk were found across the four groups. However, a P-DAPT score of ≥25 in AF patients was associated with a higher risk for hospitalizations related to cardiovascular causes (HR: 2.15 95% CI 2.00-2.3, p < .0001). Among AF patients, P-DAPT score ≥ 25 was found to be strongly associated with mortality (HR 3.5; 95% CI 2.95-4.25, p < .0001) as compared with AF patients with score < 25 (HR 1.18, 95% CI 0.88-1.54, p = .26).

CONCLUSION

In this large cohort of patients undergoing PCI, the P-DAPT score can help to identify patients at high risk for long-term mortality, particularly among those with atrial fibrillation.

Antithrombotic Therapy With Ticagrelor in Atrial Fibrillation Subjects After Percutaneous Coronary Intervention

Background: Warfarin, along with aspirin and clopidogrel, has long been recommended for patients with atrial fibrillation (AF) who are undergoing percutaneous coronary intervention with a drug-eluting stent (PCI-DES). However, this triple therapy has been known to increase the risk of bleeding complications. Meanwhile, there is no evidence from prospective trials on the use of ticagrelor in a dual therapy. We here aimed to compare the antiplatelet drug ticagrelor as a dual antithrombotic agent to aspirin and clopidogrel in bleeding events.

Methods: In this multicenter, active-controlled, open-label, randomized trial, patients with AF taking warfarin who had undergone PCI-DES were randomly assigned to the ticagrelor therapy group (Dual group) or the clopidogrel plus aspirin therapy group (Triple group). The primary and secondary endpoints were overall bleeding events and major bleeding events, respectively, according to the Thrombolysis in Myocardial Infarction (TIMI) criteria at 6 months. Cardiovascular events [re-PCI, surgical bypass, myocardial infarction (MI), heart failure, rehospitalization due to angina pectoris, stent thrombosis and death due to cardiovascular causes] at 6 months were also recorded.

Results: A total of 296 patients from 12 medical centers in China were randomized after PCI-DES to either the Dual therapy group (n = 148) or the Triple group (n = 146) for 6 months. The overall incidence of bleeding events at 6 months was 36.49% in the Dual therapy group and 35.62% in the Triple group [hazard ratio, 0.930; 95% confidence interval (CI), 0.635 to 1.361; P = 0.7088]. The incidence of the secondary endpoint over 6 months was 4.73% in the Dual therapy group and 1.37% in the Triple group (hazard ratio, 0.273; 95% CI, 0.057 to 1.315; P = 0.1056). Cardiovascular event occurrence was also comparable in both groups at 6 months (18.24 vs. 16.44%; hazard ratio, 0.845; 95% CI, 0.488 to 1.465; P = 0.5484).

Conclusions: The incidence of total bleeding events in AF patients treated with ticagrelor was comparable to that in patients treated with clopidogrel plus aspirin at 6 month; Meanwhile, the incidence of cardiovascular events were also comparable between the groups.

Clinical Trial Registration: MANJUSRI, ClinicalTrials.gov# NCT02206815, 2014, August 1^st

The prognostic impact of left ventricular thrombus resolution after acute coronary syndrome and risk modulation via antithrombotic treatment strategies

Background

Left ventricular thrombus (LVT) is a rare but dreaded complication during the acute phase of acute coronary syndrome (ACS). However, profound data on long‐term outcome and associated antithrombotic treatment strategies of this highly vulnerable patient population are scarce in current literature.

Methods

Patients presenting with ACS were screened for presence of LVT and subsequently included within a prospective clinical registry. All‐cause mortality and the composite of major adverse cardiac events (MACE) and thromboembolic events were defined as primary and secondary endpoint.

Results

Within 43 patients presenting with LVT, thrombus resolution during patient follow‐up was observed in 27 individuals (62.8%). Patients that reached a resolution of LVT experienced lower incidence rates of death (−23.9%; p = .022), MACE (−37.8%; p = .005), and thromboembolic events (−35.2%; p = .008). Even after adjustment for clinical variables, thrombus resolution showed an independent inverse association with all‐cause death with a hazard ratio (HR) of 0.14 (95% CI: 0.03–0.75; p = .021) and as well with MACE with a HR of 0.22 (95% CI: 0.07–0.68; p = .008) and thromboembolic events with a HR of 0.22 (95% CI: 0.06–0.75; p = .015). Triple antithrombotic therapy (TAT) with ticagrelor/prasugrel showed a strong and independent association with thrombus resolution with an adjusted HR of 3.25 (95% CI: 1.22–8.68; p = .019) compared to other strategies.

Conclusion

The presented data indicate a poor outcome of ACS patients experiencing LVT. In terms of a personalized risk stratification, thrombus resolution has a strong protective impact on both all‐cause death and MACE with the potential to tailor treatment decisions—including an intensified antithrombotic treatment approach—in this patient population.

Non-Vitamin K Antagonist Oral Anticoagulants and Risk of Myocardial Infarction in Patients with Atrial Fibrillation with or without Percutaneous Coronary Interventions: A Meta-Analysis

The study aimed to assess the risk of myocardial infarction (MI) and major adverse cardiac events during non-vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin therapy in patients with atrial fibrillation (AF), both treated and not treated with percutaneous coronary interventions (PCI). In a systematic search, we selected eight randomized clinical trials with a total of 81,943 patients. Dabigatran, compared to warfarin, significantly increased the risk of MI (relative risk [RR] 1.38, 95% CI 1.14-1.67), while the FXa inhibitors' effect did not differ significantly from warfarin (RR 0.96, 95% CI 0.86-1.09). The RR comparison between analyzed subgroups (dabigatran vs. FXa inhibitors) showed a significant difference (Chi2 = 9.51, df = 1, p = 0.002). In a network meta-analysis, dabigatran 110 mg b.i.d. increased the risk of MI compared to warfarin, apixaban, edoxaban, and rivaroxaban. Also, dabigatran 150 mg b.i.d. increased the risk of MI compared to warfarin, apixaban, and rivaroxaban. Moreover, we tried to estimate the treatment ranking of the best therapy for MI prevention in patients with AF treated with PCI. Rivaroxaban had a 90% probability of being ranked the best therapy for MI prevention, whereas dabigatran 110 mg had an 8.2% probability. Dabigatran 150 mg was the most effective in stroke prevention (94% probability). Each NOAC is associated with a different risk of MI. Furthermore, we should consider FXa inhibitors as the first line NOACs in AF and coronary artery disease patients. PROSPERO ID CRD42020179808.

Unmet Clinical Needs in Elderly Patients Receiving Direct Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation

Vitamin K antagonists have been used for many years as the treatment of choice for long-term oral anticoagulation in patients with non-valvular atrial fibrillation. Unfortunately, the use of those drugs in the real-world setting, particularly among elderly patients, is suboptimal because of their limitations in management. Therefore, many patients were not adequately anticoagulated. Direct oral anticoagulants have been demonstrated to overcome almost all the limitations derived from the use of vitamin K antagonists. Direct oral anticoagulants are at least as effective as vitamin K antagonists in preventing thromboembolic events in patients with non-valvular atrial fibrillation and safer in reducing the risk of intracranial haemorrhage and all-cause mortality. However, as a result of the strict inclusion and exclusion criteria applied to patients, data coming from randomized controlled trials might not apply to the general population. Furthermore, elderly patients were scarcely represented in randomized controlled trials with direct oral anticoagulants. Therefore in elderly patients with non-valvular atrial fibrillation, unmet clinical needs still exist. This review article highlights some of them and provides potential answers based on the results coming from randomized clinical trials, real-world data, and the authors' clinical experience.

[ESC guidelines 2020: acute coronary syndrome without persistent ST-segment elevation : What is new?]

The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndrome without persistent ST-segment elevation (NSTE-ACS) published in August 2020, replace the former NSTE-ACS guidelines published in 2015. These updated guidelines have some relevant changes for the clinical practice, which include the diagnostic work-up, risk stratification, antithrombotic therapy, invasive or noninvasive coronary diagnostics and also long-term treatment. New sections deal with spontaneous coronary artery dissection (SCAD), myocardial infarction with nonobstructive coronary arteries (MINOCA) and also newly introduced quality indicators for NSTE-ACS treatment. The diagnostic work-up using highly sensitive cardiac troponin (hs-cTn) assays is emphasized with the recommendation to use fast triage decisions that enable an early rule-in (no STEMI) or rule-out (NSTEMI probable) in the emergency room or chest pain unit. In antiplatelet therapy a greater individualization of the treatment concept is recommended based on the individual ischemic/thrombotic events and bleeding complications. Some new aspects were introduced for timing of invasive coronary angiography; however, principally the very high-risk group should still immediately undergo coronary angiography and the high-risk group should undergo an invasive angiography within 24 h. In risk stratification, the former intermediate risk group has been removed, instead it is now emphasized that low-risk patients should be treated similarly to patients with chronic coronary syndrome.

Direct Oral Anticoagulants Versus Vitamin-K Antagonist After PCIs in Patients With AF: A Meta-analysis of Cardiac Ischemic Events

BACKGROUND

Clinical trials have assessed the effect of direct oral antagonists (DOACs) in patients with atrial fibrillation (AF) after percutaneous coronary interventions (PCI). Studies were designed to test the effect on bleeding incidence, but concerns related to safety on ischemic events remain.

METHODS

We performed a meta-analysis with currently available studies involving DOACs versus Vitamin-K antagonist (VKA) in patients with AF after PCI. The primary endpoint was the incidence of cardiac ischemic events, including myocardial infarction and stent thrombosis. Secondary endpoints were the incidence of stroke, all-cause mortality, and major bleeding.

RESULTS

Eleven thousand twenty-three patients were included in the analysis: 5510 receiving DOACs and 5513 VKA. A total of 190 cases of myocardial infarction were registered in patients treated with DOACs and 177 in patients on VKA, and no statistical difference was noted [relative risk (RR): 1.07 95% confidence interval (CI) 0.88-1.31]. The incidence of stent thrombosis was very low with no differences between both treatment strategies (RR: 1.14 95% CI 0.76-1.71). The incidence of cardiac ischemic events was the same in patients receiving DOACs or VKA (HR 1.09 95% CI 0.91-1.30). No differences were observed in the incidence of stroke (RR: 0.86 95% CI 0.61-1.23) or mortality (RR: 1.09, 95% CI 0.90-1.31). Treatment with DOACs was associated with 34% reduction in major bleeding (RR: 0.66, 95% CI 0.54-0.81).

CONCLUSIONS

Treatment with DOACs in patients with AF after a PCI do not increase the risk of cardiac ischemic events, stroke, or death and reduce the incidence of major bleeding by 34% as compared with VKA.

A predictive nomogram of bleeding risk in patients with atrial fibrillation after drug-eluting stent implantation

BACKGROUND

The use of anticoagulants and antiplatelet therapies is associated with a higher risk of bleeding in atrial fibrillation (AF) patients after percutaneous coronary intervention, especially after stent implantation. However, no accurate bleeding risk prediction tool has been developed for these patients. The aim of this study was thus to establish a bleeding risk prediction model (predictive nomogram) for patients with AF after stent implantation.

METHODS

Construction of the predictive nomogram was based on a retrospective study, which enrolled 943 AF patients who underwent drug-eluting stent implantation between May 2012 and September 2016. A range of factors, including demographics, comorbidities, medication strategies, arterial access, and laboratory tests, were collected as baseline data. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis were used to identify the key clinical features for construction of the predictive nomogram. The concordance index (C-index) and internal validation were used to evaluate the efficacy of the nomogram.

RESULTS

Of the 943 AF patients that underwent stent implantation, the occurrence of bleeding events was 8.2% (77 out of 943). Key predictors included the number of antiplatelet drugs, peptic ulcer, cerebral infarction, type 2 diabetes, thrombocytopenia, anemia, prior myocardial infarction, sex (male), use of anticoagulant drugs, liver dysfunction, hypertension, and acute myocardial infarction. These predictors were used to construct the nomogram. The C-index for the prediction of bleeding risk by the nomogram was 0.841 (95% CI: 0.79-0.89), which indicated good discrimination and calibration. The C-index of internal validation was 0.795, which demonstrated good efficacy of the model.

CONCLUSIONS

This study suggests that our novel nomogram can accurately predict bleeding risk in AF patients after stent implantation during hospitalization, thereby helping to avoid complications. The nomogram may also be helpful for the creation of individualized post-discharge medication strategies.

Safety and efficacy outcomes of double vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials

AIMS

To investigate the safety and efficacy of double vs. triple antithrombotic therapy (DAT vs. TAT) in patients with atrial fibrillation (AF) and acute coronary syndrome or who underwent percutaneous coronary intervention (PCI).

METHODS AND RESULTS

A systematic review and meta-analysis was performed using PubMed to search for non-vitamin K antagonist oral anticoagulant (NOAC)-based randomized clinical trials comparing DAT vs. TAT in AF patients undergoing PCI. Four trials encompassing 10 234 patients (DAT = 5496 vs. TAT = 4738) were included. The primary safety endpoint (ISTH major or clinically relevant non-major bleeding) was significantly lower with DAT compared with TAT [risk ratio (RR) 0.66, 95% confidence interval (CI) 0.56-0.78; P < 0.0001; I2 = 69%], which was consistent across all available bleeding definitions. This benefit was counterbalanced by a significant increase of stent thrombosis (RR 1.59, 95% CI 1.01-2.50; P = 0.04; I2 = 0%) and a trend towards higher risk of myocardial infarction with DAT. There were no significant differences in all-cause and cardiovascular death, stroke and major adverse cardiovascular events. The comparison of NOAC-based DAT vs. vitamin K antagonist (VKA)-TAT yielded consistent results and a significant reduction of intracranial haemorrhage (RR 0.33, 95% CI 0.17-0.65; P = 0.001; I2 = 0%).

CONCLUSION

Double antithrombotic therapy, particularly if consisting of a NOAC instead of VKA and a P2Y12 inhibitor, is associated with a reduction of bleeding, including major and intracranial haemorrhages. This benefit is however counterbalanced by a higher risk of cardiac-mainly stent-related-but not cerebrovascular ischaemic occurrences.

Randomised trials and meta-analyses of double vs triple antithrombotic therapy for atrial fibrillation-ACS/PCI: A critical appraisal

•

The optimal antithrombotic regimen to be used in patients with AF and PCI or ACS is still debated.

•

Each of the six randomised controlled trials comparing double to triple therapy has limitations.

•

None was powered to assess differences between treatment arms in ischaemic event rates.

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The contrasting results regarding ischaemic events within published meta-analyses can be explained by heterogeneity, incompleteness and varying definitions of stent thrombosis.

•

The overall reduced bleeding rates, but increased early definite and probable stent thrombosis rates with double versus triple antithrombotic therapy encourage consideration of triple therapy during the first weeks from PCI followed by double therapy.

Long-term prognosis of de novo atrial fibrillation during acute myocardial infarction: the impact of anti-thrombotic treatment strategies

AIMS

While the prognosis of patients presenting with de novo atrial fibrillation (AF) during the acute phase of myocardial infarction has been controversially discussed, it seems intuitive that affected individuals have an increased risk for both thrombo-embolic events and mortality. However, profound data on long-term outcome of this highly vulnerable patient population are not available in current literature. Therefore, we aimed to investigate the impact of de novo AF and associated anti-thrombotic treatment strategies on the patient outcome from a long-term perspective.

METHODS AND RESULTS

Patients presenting with acute myocardial infarction, treated at the Medical University of Vienna, were enrolled within a clinical registry and screened for the development of de novo AF. After discharge, participants were followed prospectively over a median time of 8.6 years. Primary study endpoint was defined as cardiovascular mortality. Out of 1372 enrolled individuals 149 (10.9%) developed de novo AF during the acute phase of acute myocardial infarction. After a median follow-up time of 8.6 years, a total of 418 (30.5%) died due to cardiovascular causes, including 93 (62.4%) in the de novo AF subgroup. We found that de novo AF was significantly associated with long-term cardiovascular mortality with an adjusted HR of 1.45 (95% CI 1.19-2.57; P < 0.001). While patients with de novo AF were less likely to receive a triple anti-thrombotic therapy as compared to patients with pre-existing AF at time of discharge, this therapeutic approach showed a strong and inverse association with mortality in de novo AF, with an adj. HR of 0.86 (95% CI 0.45-0.92; P = 0.012).

CONCLUSION

De novo AF was independently associated with a poor prognosis with a 67% increased risk of long-term cardiovascular mortality. Intensified anti-thrombotic treatment in this high-risk patient population might be considered.