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Castiello DS, Buongiorno F, Manzi L, Narciso V, Forzano I, Florimonte D, Sperandeo L, Canonico ME, Avvedimento M, Paolillo R, Spinelli A, Cristiano S, Simonetti F, Semplice F, D’Alconzo D, Vallone DM, Giugliano G, Sciahbasi A, Cirillo P, Gragnano F, Calabrò P, Esposito G, Gargiulo G. Procedural and Antithrombotic Therapy Optimization in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Narrative Review. J Cardiovasc Dev Dis 2025; 12:142. [PMID: 40278201 PMCID: PMC12028227 DOI: 10.3390/jcdd12040142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2025] [Revised: 04/03/2025] [Accepted: 04/05/2025] [Indexed: 04/26/2025] Open
Abstract
In the past decades, percutaneous coronary intervention (PCI) has become the most common modality for myocardial revascularization in patients with coronary artery disease (CAD). Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is essential in all patients undergoing PCI to prevent thrombotic complications. A large proportion of patients undergoing PCI also have concomitant atrial fibrillation (AF), thus requiring an oral anticoagulant (OAC) to prevent ischemic stroke or systemic embolism. However, the association between OAC and DAPT further increases the risk of bleeding. Compared with a triple antithrombotic therapy (TAT), dual antithrombotic therapy (DAT) has shown to reduce bleeding events, but at the cost of higher risk of stent thrombosis. In this field, patients with AF undergoing PCI represent a special population with significant challenges, and several strategies are needed to reduce the risk for bleeding complications. In this review, we will discuss both the procedural and antithrombotic strategies to optimize ischemic and bleeding outcomes in patients with AF undergoing PCI.
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Affiliation(s)
- Domenico Simone Castiello
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Federica Buongiorno
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Lina Manzi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Viviana Narciso
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Imma Forzano
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Domenico Florimonte
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Luca Sperandeo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Mario Enrico Canonico
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Roberta Paolillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Alessandra Spinelli
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Stefano Cristiano
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Fiorenzo Simonetti
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Federica Semplice
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Dario D’Alconzo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Donato Maria Vallone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.G.); (P.C.)
- Division of Cardiology, Azienda Ospedaliera di Rilievo Nazionale Sant’Anna e San Sebastiano, 81100 Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (F.G.); (P.C.)
- Division of Cardiology, Azienda Ospedaliera di Rilievo Nazionale Sant’Anna e San Sebastiano, 81100 Caserta, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy; (D.S.C.); (F.B.); (L.M.); (V.N.); (I.F.); (D.F.); (L.S.); (M.E.C.); (M.A.); (R.P.); (A.S.); (S.C.); (F.S.); (F.S.); (D.D.); (D.M.V.); (G.G.); (P.C.); (G.E.)
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Ingraham BS, Valgimigli M, Angiolillo DJ, Capodanno D, Rao SV, Urban P, Singh M. Relevance of High Bleeding Risk and Postdischarge Bleeding in Patients Undergoing Percutaneous Coronary Intervention. Mayo Clin Proc 2025; 100:304-331. [PMID: 39909670 DOI: 10.1016/j.mayocp.2024.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 08/28/2024] [Accepted: 09/09/2024] [Indexed: 02/07/2025]
Abstract
Bleeding avoidance strategies are critical in the modern era of percutaneous coronary intervention; however, most efforts are geared toward reducing access-related complications. Improvements in procedural techniques (radial access, improved procedural anticoagulation regimens, etc) and modifications in postdischarge pharmacotherapy (shortened dual antiplatelet therapy, genotype-guided P2Y12 inhibition, etc) that led to a decline in bleeding related to percutaneous procedures were largely offset by increases in complexity and performance of percutaneous coronary intervention in high-risk patients. Among patients presenting with acute coronary syndrome, aggressive antiplatelet regimens with potent P2Y12 inhibitors are typically prescribed for a longer duration, prioritizing reduction in ischemic events over bleeding risk. Because postdischarge bleeding connotes an adverse prognosis similar to an ischemic event, postprocedure freedom from adverse outcomes can be best tailored by individualizing and recognizing the patient's bleeding and ischemic risks. This review of the contemporary and historical literature (PubMed, EMBASE, Cochrane Library) summarizes the available data, provides strategies to navigate these complex decisions, and helps individualize antithrombotic therapy.
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Affiliation(s)
| | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera italiana, Lugano, Switzerland
| | | | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Sunil V Rao
- Division of Cardiology, NYU Langone Health and NYU Grossman School of Medicine, New York, NY
| | | | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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Mazzone PM, Spagnolo M, Capodanno D. Antithrombotic Therapy in Patients with Chronic Coronary Syndromes. Interv Cardiol Clin 2024; 13:493-505. [PMID: 39245549 DOI: 10.1016/j.iccl.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
The antithrombotic management of chronic coronary syndrome (CCS) involves a 6-month course of dual antiplatelet therapy (DAPT), followed by chronic aspirin therapy. In patients with a baseline indication for anticoagulation, a variable duration of triple antithrombotic therapy is administered, followed by dual antithrombotic therapy until the sixth month post-percutaneous coronary intervention (PCI), and ultimately a transition to chronic anticoagulation. However, advancements in stent technology reducing the risk of stent thrombosis and a growing focus on the impact of bleeding on prognosis have prompted the development of new therapeutic strategies. These strategies aim to enhance protection against ischemic events in the initial stages after PCI while mitigating the risk of bleeding in the long term. This article delineates the therapeutic strategies outlined in European and American guidelines for CCS management, with special attention to investigational strategies.
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Affiliation(s)
- Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Via Santa Sofia, 78, Catania 95123, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Via Santa Sofia, 78, Catania 95123, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Via Santa Sofia, 78, Catania 95123, Italy.
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Manzi L, Florimonte D, Forzano I, Buongiorno F, Sperandeo L, Castiello DS, Paolillo R, Giugliano G, Giacoppo D, Sciahbasi A, Cirillo P, Esposito G, Gargiulo G. Antiplatelet Therapy in Patients Requiring Oral Anticoagulation and Undergoing Percutaneous Coronary Intervention. Interv Cardiol Clin 2024; 13:527-541. [PMID: 39245552 DOI: 10.1016/j.iccl.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is fundamental in all patients undergoing percutaneous coronary intervention (PCI) to prevent coronary thrombosis. In patients with atrial fibrillation (AF), an oral anticoagulant gives protection against ischemic stroke or systemic embolism. AF-PCI patients are at high bleeding risk and decision-making regarding the optimal antithrombotic therapy remains challenging. Dual antithrombotic therapy (DAT) has been shown to reduce bleeding events but at the cost of a higher risk of stent thrombosis. Further studies are needed to clarify the optimal duration of triple antithrombotic therapy (TAT) or DAT and the role of more potent antiplatelet drugs.
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Affiliation(s)
- Lina Manzi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Domenico Florimonte
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Imma Forzano
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Federica Buongiorno
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Luca Sperandeo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | | | - Roberta Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Daniele Giacoppo
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy.
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Sammut MA, Storey RF. Antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2024; 22:471-482. [PMID: 39428686 DOI: 10.1080/14779072.2024.2388265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/31/2024] [Indexed: 10/22/2024]
Abstract
INTRODUCTION Patients who undergo percutaneous coronary intervention (PCI) with stenting usually require a period of dual antiplatelet therapy (DAPT) but, when an indication for long-term oral anticoagulation (OAC) such as atrial fibrillation (AF) coexists, triple antithrombotic therapy (TAT) with DAPT and OAC causes concern for excessive bleeding. Achieving the right balance between bleeding and adequate protection from ischemic events remains an issue of debate and subject to ongoing investigation of various antithrombotic regimens and durations. AREAS COVERED This review describes the landmark clinical trials comparing TAT to a period of dual antithrombotic therapy (DAT) and subsequent meta-analyses. It also describes the international recommendations that have been derived from this evidence and identifies outstanding issues that could be addressed in upcoming or future trials. EXPERT OPINION The current recommended default strategy of a short period of TAT with clopidogrel followed by the withdrawal of aspirin faces a challenge from the prospect of more consistent P2Y12 inhibition provided by ticagrelor and prasugrel. Ticagrelor monotherapy has already been trialed in patients after PCI without an indication for OAC. DAT with ticagrelor or prasugrel immediately post-procedure could emerge as a comparably safe and more efficacious regimen than one involving clopidogrel in the right setting.
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Affiliation(s)
- Mark Anthony Sammut
- Cardiovascular Research Unit, Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert F Storey
- Cardiovascular Research Unit, Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Triska J, Haddadin F, Madanat L, Jabri A, Daher M, Birnbaum Y, Jneid H. The Cost of Breaking Even: a Perspective on the Net Clinical Impact of Adding Aspirin to Antithrombotic Therapies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2024; 38:605-619. [PMID: 35829979 DOI: 10.1007/s10557-022-07367-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2Y12 receptor inhibitor, and aspirin for 1 week or until hospital discharge in patients with atrial fibrillation (AF) undergoing PCI, and up to 4 weeks in individuals considered to be at high-risk for ischemic events, followed by discontinuation of aspirin and continuation of OAC and a P2Y12 inhibitor for up to 12 months. METHODS We examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2Y12 inhibitor with and without aspirin in AF patients undergoing PCI with stenting. RESULTS Data comparing dual therapy with OAC and a P2Y12 inhibitor alone to triple therapy with OAC, a P2Y12 inhibitor, and aspirin with respect to the risks of MACEs, including stent thrombosis within the first 30 days, are underpowered and inconclusive. The addition of aspirin does not appear to be associated with a decreased risk of ischemic events, even in patients with high-risk CHA2DS2-VASc scores, but does significantly increase bleeding hazards. The increased safety of newer generation drug-eluting stents may have further minimized any theoretical anti-ischemic benefits of aspirin. The possible attenuation of the pleiotropic effects of concomitant cardiovascular medications by aspirin may also have been a contributing factor. CONCLUSION The addition of aspirin to OAC and a P2Y12 inhibitor is likely associated with a net clinical harm in patients with AF who undergo PCI with stenting, even within the first 1-4 weeks after PCI. Revisiting the guideline recommendations to administer aspirin in this timeframe may be warranted.
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Affiliation(s)
- Jeffrey Triska
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Faris Haddadin
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Luai Madanat
- Department of Medicine, William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Marilyne Daher
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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Bachorski W, Bychowski J, Gruchała M, Jaguszewski M. Two Approaches to Triple Antithrombotic Therapy in Patients with Acute Coronary Syndrome and Non-Valvular Atrial Fibrillation Treated with Percutaneous Coronary Intervention: Which Is More Efficient and Safer? Diagnostics (Basel) 2023; 13:3055. [PMID: 37835798 PMCID: PMC10572308 DOI: 10.3390/diagnostics13193055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) treated with percutaneous coronary intervention (PCI) are at high risk of bleeding and thromboembolic events. Thus, optimal treatment strategies in this challenging subset have been controversial. Herein, we aim to investigate different triple antithrombotic treatment (TAT) strategies in patients with ACS and AF after PCI. METHODS This was a retrospective, single-center study based on all consecutive patients with the diagnosis of ACS and AF treated with vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) plus dual antiplatelet therapy using a P2Y12 inhibitor (clopidogrel) and aspirin (for 1 to 3 months) and observed for 12 months for major adverse cardiac events (MACE) and major or clinically relevant non-major bleeding incidents. RESULTS MACE occurred in 26.6% of patients treated with the VKA and 30.9% with NOAC (p = 0.659). Bleeding occurred in 7.8% of patients treated with VKA and 7.4% with NOAC (ns). CONCLUSIONS Among patients with ACS and AF who had undergone PCI, there was no significant difference in the risk of bleeding and ischemic events among those who received TAT with NOAC and VKA.
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Affiliation(s)
- Witold Bachorski
- Department of Cardiology, Medical University of Gdansk, M. Skłodowskiej-Curie 3a, 80-210 Gdansk, Poland
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Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Greco A, Laudani C, Rochira C, Capodanno D. Antithrombotic Management in AF Patients Following Percutaneous Coronary Intervention: A European Perspective. Interv Cardiol 2023; 18:e05. [PMID: 37601736 PMCID: PMC10433110 DOI: 10.15420/icr.2021.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/20/2022] [Indexed: 08/22/2023] Open
Abstract
AF is a highly prevalent disease, often requiring long-term oral anticoagulation to prevent stroke or systemic embolism. Coronary artery disease, which is common among AF patients, is often referred for myocardial revascularisation by percutaneous coronary intervention (PCI), which requires dual antiplatelet therapy to minimise the risk of stent-related complications. The overlap of AF and PCI is a clinical conundrum, especially in the early post-procedural period, when both long-term oral anticoagulation and dual antiplatelet therapy are theoretically indicated as a triple antithrombotic therapy. However, stacking drugs is not a desirable option because of the increased bleeding risk. Several strategies have been investigated to mitigate this concern, including shortening triple antithrombotic therapy duration and switching to a dual antithrombotic regimen. This review analyses the mechanisms underlying thrombotic complications in AF-PCI, summarises evidence surrounding antithrombotic therapy regimens and reports and comments on the latest European guidelines.
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Affiliation(s)
- Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Claudio Laudani
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Carla Rochira
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
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10
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society. Europace 2022; 24:1844-1871. [PMID: 35323922 PMCID: PMC11636575 DOI: 10.1093/europace/euac020] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 12/26/2022] Open
Abstract
Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK
- Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, Ciber Cardiovascular (CIBERCV), L’Hospitalet de Llobregat, Barcelona, Spain
- BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d’Investigació Biomèdica de Bellvitge—IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, España
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases—AUSL Romagna, SMaria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
- CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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11
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Greco A, Capodanno D. Therapeutic uncertainties: first finding of atrial fibrillation in acute coronary syndrome. Eur Heart J Suppl 2022; 24:I43-I46. [PMID: 36380790 PMCID: PMC9653142 DOI: 10.1093/eurheartjsupp/suac072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
Atrial fibrillation (AF) and coronary artery disease share several risk factors and their simultaneous presentation in the same patient, sometimes in the course of acute coronary syndrome (ACS), is not a rare occurrence. Patients with AF and ACS represent an important clinical challenge in terms of diagnosis, prognosis and therapy. From a diagnostic point of view, AF may be new onset as a complication of ACS, or a pre-existing asymptomatic AF that is occasionally diagnosed during ACS. Regarding the prognosis, AF, whether new onset or already known, has been shown to exert a negative prognostic impact during ACS. Finally, the main therapeutic dilemma concerns the selection of the optimal antithrombotic therapy, which, at least in the first period following ACS, would require the combination of anticoagulant and antiplatelet drugs, with a consequent increase in the risk of bleeding complications. Several randomized studies have evaluated the therapeutic options in patients with AF and coronary artery disease, overall showing the advantage of a dual therapy with an antiplatelet and an anticoagulant compared with a long-term triple therapy with dual antiplatelet and anticoagulant therapy; the analyses of the ACS subgroups of these randomized studies confirmed such results also in the acute setting.
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Affiliation(s)
- Antonio Greco
- A.O.U. Policlinico ‘G. Rodolico—San Marco’, University of Catania, Catania
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12
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper. Thromb Haemost 2022; 122:1625-1652. [PMID: 35793691 DOI: 10.1055/s-0042-1750385] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge and Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, München, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Zangrillo A, Lomivorotov VV, Pasyuga VV, Belletti A, Gazivoda G, Monaco F, Nigro Neto C, Likhvantsev VV, Bradic N, Lozovskiy A, Lei C, Bukamal NAR, Silva FS, Bautin AE, Ma J, Yong CY, Carollo C, Kunstyr J, Wang CY, Grigoryev EV, Riha H, Wang C, El-Tahan MR, Scandroglio AM, Mansor M, Lembo R, Ponomarev DN, Bezerra FJL, Ruggeri L, Chernyavskiy AM, Xu J, Tarasov DG, Navalesi P, Yavorovskiy A, Bove T, Kuzovlev A, Hajjar LA, Landoni G. Effect of Volatile Anesthetics on Myocardial Infarction After Coronary Artery Surgery: A Post Hoc Analysis of a Randomized Trial. J Cardiothorac Vasc Anesth 2022; 36:2454-2462. [PMID: 35168907 DOI: 10.1053/j.jvca.2022.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/08/2021] [Accepted: 01/02/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG). DESIGN A post hoc analysis of a randomized trial. SETTING Cardiac surgical operating rooms. PARTICIPANTS Patients undergoing elective, isolated CABG. INTERVENTIONS Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes. MEASUREMENTS AND MAIN RESULTS A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03). CONCLUSIONS An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.
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Affiliation(s)
- Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Department of Anesthesiology and Intensive Care, Novosibirsk State University, Novosibirsk, Russia
| | - Vadim V Pasyuga
- Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russia
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gordana Gazivoda
- Department of Anaesthesia and Intensive Care, Cardiovascular Institute Dedinje, Belgrade, Serbia
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Caetano Nigro Neto
- Anesthesia Section, Department of Cardiovascular Surgery, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Valery V Likhvantsev
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia; V. Negovsky Reanimatology Research Institute, Moscow, Russia
| | - Nikola Bradic
- Department of Cardiovascular Anesthesiology and Intensive Care Medicine, Clinical Department of Anesthesiology, Resuscitation and Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia; Department of Biomedical Sciences, University North, Varazdin, Croatia
| | - Andrey Lozovskiy
- Department of Anesthesia and Intensive Care, Ural Institute of Cardiology, Ekaterinburg, Russia
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, Shaanxi, China
| | - Nazar A R Bukamal
- Cardiothoracic ICU and Anesthesia Department, Mohammed Bin Khalifa Cardiac Center, Riffa, Bahrain
| | | | - Andrey E Bautin
- Laboratory for Anesthesiology and Intensive Care, Almazov National Medical Research Center, Saint Petersburg, Russia
| | - Jun Ma
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chow Yen Yong
- Department of Anaesthesiology and Intensive Care, Hospital Pulau Pinang, Pulau Pinang, Malaysia
| | - Cristiana Carollo
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Jan Kunstyr
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine Charles University and General University Hospital, Prague, Czech Republic
| | - Chew Yin Wang
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Evgeny V Grigoryev
- Intensive Care Unit, Scientific Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - Hynek Riha
- Cardiothoracic Anesthesiology and Intensive Care Medicine, Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Chengbin Wang
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Mohamed R El-Tahan
- Department of Anesthesiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marzida Mansor
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dmitry N Ponomarev
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Francisco José Lucena Bezerra
- Anesthesia Section, Department of Cardiovascular Surgery, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alexander M Chernyavskiy
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Junmei Xu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Dmitry G Tarasov
- Department of Cardiac Surgery, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russian Federation
| | - Paolo Navalesi
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy; Department of Medicine, University of Padua, Padua, Italy
| | - Andrey Yavorovskiy
- Federal Research and Clinical Center of Resuscitation and Rehabilitation, Moscow, Russia
| | - Tiziana Bove
- Department of Medicine (DAME), University of Udine, Udine, Italy; Department of Anesthesia and Intensive Care Medicine, ASUFC University-Hospital of Central Friuli, Udine, Italy
| | - Artem Kuzovlev
- V. Negovsky Reanimatology Research Institute, Moscow, Russia
| | - Ludhmila A Hajjar
- Department of Cardiopneumology, Instituto do Coração, Universidade de São Paulo, São Paulo, Brazil; Intensive Care Unit, Hospital SirioLibanes, São Paulo, Brazil
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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14
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Fanaroff AC, Lopes RD. The role of triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Prog Cardiovasc Dis 2021; 69:11-17. [PMID: 34883097 DOI: 10.1016/j.pcad.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel forms the backbone of secondary prevention in patients with acute coronary syndromes (ACS) or who undergo percutaneous coronary intervention (PCI), but in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is superior to antiplatelet therapy for the prevention of stroke and systemic embolism. Patients with AF who undergo PCI or have an ACS event therefore have an indication for both OAC and DAPT, so-called triple antithrombotic therapy. However, observational analyses have shown that the annual rate of major bleeding on triple therapy exceeds 10%. For this reason, five major randomized clinical trials have compared double antithrombotic therapy with OAC and a P2Y12 inhibitor versus triple therapy in patients with AF who underwent PCI or had an ACS event. Each of the trials showed that double antithrombotic therapy reduced the rate of major and clinically relevant non-major bleeding compared with triple therapy and was non-inferior for prevention of ischemic events, including cardiovascular death, myocardial infarction, or stroke. In the one trial that directly compared warfarin with a non-vitamin K antagonist oral anticoagulant (NOAC), apixaban reduced the rate of major or clinically relevant non-major bleeding compared with warfarin and was non-inferior with respect to prevention of ischemic events. As a result of these trials, consensus guidelines recommend that patients with AF who undergo PCI or have an ACS event should be treated with triple antithrombotic therapy (OAC + P2Y12 inhibitor + aspirin) for 7 days or less, followed by double antithrombotic therapy (OAC + P2Y12 inhibitor) for 6 to 12 months.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Renato D Lopes
- Division of Cardiovascular Medicine and Duke Clinical Research Institute, Durham, NC, United States of America.
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15
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Rivolo S, Di Fusco M, Polanco C, Kang A, Dhanda D, Savone M, Skandamis A, Kongnakorn T, Soto J. Cost-effectiveness analysis of apixaban versus vitamin K antagonists for antithrombotic therapy in patients with atrial fibrillation after acute coronary syndrome or percutaneous coronary intervention in Spain. PLoS One 2021; 16:e0259251. [PMID: 34767564 PMCID: PMC8589164 DOI: 10.1371/journal.pone.0259251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 10/17/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND/OBJECTIVE AUGUSTUS trial demonstrated that, for patients with atrial fibrillation (AF) having acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), an antithrombotic regimen with apixaban and P2Y12 resulted in less bleeding, fewer hospitalizations, and similar ischemic events than regimens including a vitamin K antagonist (VKA), aspirin, or both. This study objective was to evaluate long-term health and economic outcomes and the cost-effectiveness of apixaban over VKA, as a treatment option for patients with AF having ACS/PCI. METHODS A lifetime Markov cohort model was developed comparing apixaban versus VKA across multiple treatment strategies (triple [with P2Y12 + aspirin] or dual [with P2Y12] therapy followed by monotherapy [apixaban or VKA]; triple followed by dual and then monotherapy; dual followed by monotherapy). The model adopted the Spanish healthcare perspective, with a 3-month cycle length and costs and health outcomes discounted at 3%. RESULTS Treatment with apixaban resulted in total cost savings of €883 and higher life years (LYs) and quality-adjusted LYs (QALYs) per patient than VKA (net difference, LYs: 0.13; QALYs: 0.11). Bleeding and ischemic events (per 100 patients) were lower with apixaban than VKA (net difference, -13.9 and -1.8, respectively). Incremental net monetary benefit for apixaban was €3,041, using a willingness-to-pay threshold of €20,000 per QALY. In probabilistic sensitivity analysis, apixaban was dominant in the majority of simulations (92.6%), providing additional QALYs at lower costs than VKA. CONCLUSIONS Apixaban was a dominant treatment strategy than VKA from both the Spanish payer's and societal perspectives, regardless of treatment strategy considered.
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Affiliation(s)
| | | | | | - Amiee Kang
- Bristol Myers Squibb, Lawrenceville, New Jersey, United States of America
| | - Devender Dhanda
- Bristol Myers Squibb, Lawrenceville, New Jersey, United States of America
| | - Mirko Savone
- Pfizer Inc, New York, New York, United States of America
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16
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Riesinger L, Strobl C, Leistner DM, Gori T, Akin I, Mehr M, Kellnar A, Mahabadi AA, Bogossian H, Block M, Edelmann F, Sarafoff N, Sibbing D, Ince H, Rassaf T, Mansmann U, Mehilli J, Kääb S, Hausleiter J, Massberg S, Wakili R. Apixaban versus PhenpRocoumon: Oral AntiCoagulation plus antiplatelet tHerapy in patients with Acute Coronary Syndrome and Atrial Fibrillation (APPROACH-ACS-AF): Rationale and design of the prospective randomized parallel-group, open-label, blinded-endpoint, superiority, multicenter-trial of a triple therapy versus a dual therapy in patients with Atrial Fibrillation and Acute Coronary Syndrome undergoing coronary stenting. IJC HEART & VASCULATURE 2021; 35:100810. [PMID: 34258380 PMCID: PMC8256176 DOI: 10.1016/j.ijcha.2021.100810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND A regimen of dual (DAT) vs. triple (TAT) antithrombotic therapy reduces bleeding in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). However, recent evidence suggests that DAT may be associated with an increased ischemic risk. This raises the question whether DAT rather than TAT should be recommended to AF patients that undergo PCI for acute coronary syndrome (ACS), carrying a particularly high risk of both bleeding and ischemic events, studied only as subgroups of previous trials. METHODS AND DESIGN The APPROACH-ACS-AF-(DZHK-7) trial is a multicenter prospective, randomized, open-label, blinded endpoint (PROBE) trial which will include patients presenting with an ACS managed by PCI and requiring oral anticoagulation (OAC) due to AF. The trial will test, whether a DAT-regimen comprising clopidogrel plus the non-Vitamin-K-antagonist oral anticoagulant (NOAC) apixaban is superior to a TAT-regimen of vitamin-K-antagonist (VKA) plus dual anti-platelet therapy (APT) with respect to bleeding. A total of 400 patients will be randomized 1:1 to a control-arm with guideline-recommended TAT with VKA plus clopidogrel and acetylsalicylic-acid and a study arm receiving DAT comprising apixaban plus clopidogrel. Patients will be followed-up for 6 months. The primary endpoint of the study is the cumulative incidence of BARC type ≥2 bleeding, secondary endpoints include a composite clinical ischemic outcome and net clinical outcome. CONCLUSIONS APPROACH-ACS-AF is the first trial dedicated to ACS patients, testing whether in terms of bleeding a DAT with NOAC is superior to a TAT regimen with VKA in high-risk ACS patients with AF.
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Affiliation(s)
- Lisa Riesinger
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Claudia Strobl
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - David M. Leistner
- Department of Cardiology, Charité University of Medicine, Berlin, Campus Benjamin Franklin, Germany and Berlin Institute of Health (BIH), 10117 Berlin, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Tommaso Gori
- Center for Cardiology, Cardiology 1, Universitätsmedizin Mainz, Mainz, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Rhine-Main, Germany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Germany
| | - Michael Mehr
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Antonia Kellnar
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Amir A. Mahabadi
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Harilaos Bogossian
- Märkische Kliniken GmbH, Klinikum Lüdenscheid, Lüdenscheid, Germany
- Department of Cardiology, University Witten/Herdecke, Witten, Germany
| | - Michael Block
- Department of Cardiology, Augustinum Hospital, Munich, Germany
| | - Frank Edelmann
- DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
- Department of Internal Medicine and Cardiology, Charité University Hospital (Campus Virchow Klinikum), Berlin, Germany
| | - Nikolaus Sarafoff
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
| | - Dirk Sibbing
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Hüseyin Ince
- Department of Cardiology, Rostock University Medical Center, Rostock, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ulrich Mansmann
- Department of Medical Information Processing, Biometry and Epidemiology (IBE), Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
| | - Julinda Mehilli
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
- Department of Medicine I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Stefan Kääb
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
| | - Reza Wakili
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80802 Munich, Germany
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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17
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Angiolillo DJ, Bhatt DL, Cannon CP, Eikelboom JW, Gibson CM, Goodman SG, Granger CB, Holmes DR, Lopes RD, Mehran R, Moliterno DJ, Price MJ, Saw J, Tanguay JF, Faxon DP. Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention: A North American Perspective: 2021 Update. Circulation 2021; 143:583-596. [PMID: 33555916 DOI: 10.1161/circulationaha.120.050438] [Citation(s) in RCA: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor, preferably clopidogrel, in combination with a non-vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
| | - John W Eikelboom
- Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, Canada (J.W.E.)
| | - C Michael Gibson
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Shaun G Goodman
- St Michael's Hospital, University of Toronto, Canada (S.G.G.).,The Canadian Heart Research Centre, Toronto, Canada (S.G.G.).,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.G.G.)
| | | | - David R Holmes
- Division of Cardiology, Mayo Clinic, Rochester, MN (D.R.H.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., R.D.L.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - David J Moliterno
- Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.)
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada (J.S.)
| | - Jean-Francois Tanguay
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada (J.-F.T.)
| | - David P Faxon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
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18
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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19
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Fanaroff AC, Lopes RD. Antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention: balance best with double antithrombotic therapy. Eur Heart J 2020; 41:4505-4507. [PMID: 33099612 DOI: 10.1093/eurheartj/ehaa683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, and Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
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20
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Hammwöhner M, Goette A. Ten years of non-vitamin K antagonists oral anticoagulants for stroke prevention in atrial fibrillation: is warfarin obsolete? Eur Heart J Suppl 2020; 22:O28-O41. [PMID: 33380942 PMCID: PMC7753780 DOI: 10.1093/eurheartj/suaa177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Currently, four non-vitamin K antagonists oral anticoagulants (NOACs) are available for stroke prevention in atrial fibrillation (AF). These have been in clinical use for up to 10 years now. Besides data of the initial phase III clinical trials, now clinical data, several sub-studies, meta-analyses, and studies in special clinical settings and specific patient populations are available. This review shall give an overview on the history of NOAC development, sum up study data and 'real-world' clinical data as well as discuss several special clinical settings like NOAC treatment in patients that require coronary artery stenting or cardioversion (CV). Furthermore, treatment considerations in special patient populations like patients with renal impairment, obesity, or patients requiring NOACs for secondary prevention are discussed. The significance of NOAC treatment will be discussed under consideration of the recently published 2020 ESC/EACTS Guidelines for the diagnosis and management of AF.
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Affiliation(s)
| | - Andreas Goette
- St. Vincenz-Hospital, Am Busdorf 2, 33098 Paderborn, Germany
- Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
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21
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Galli M, Capodanno D, Andreotti F, Crea F, Angiolillo DJ. Safety and efficacy of P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary interventions. Expert Opin Drug Saf 2020; 20:9-21. [PMID: 33180563 DOI: 10.1080/14740338.2021.1850691] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Antiplatelet therapy represents a key strategy for the prevention of thrombotic complications in patients with both acute and chronic coronary syndromes, particularly those undergoing percutaneous coronary intervention (PCI). Nevertheless, dual antiplatelet therapy (DAPT) is associated with a bleeding risk proportionate to its duration. Ever growing appreciation of the prognostic implications associated with bleeding and the development of safer stent platforms over the past years have led to a number of novel antiplatelet treatment strategies being tested among patients undergoing PCI. Areas covered: P2Y12 inhibitor monotherapy after ashort course DAPT has emerged as ableeding reduction strategy to mitigate such risk while still preventing thrombotic complications. In this review we describe the latest evidence regarding the safety and efficacy of P2Y12 inhibitor monotherapy in patients undergoing PCI in different clinical settings. Expert opinion: P2Y12 inhibitor monotherapy after a brief period of DAPT has emerged as an effective approach to reduce the risk of bleeding without any tradeoff in efficacy (i.e., thrombotic complications). This strategy has shown consistent findings in a number of different clinical settings of patients undergoing PCI. Nevertheless, unanswered questions on the ideal patient and the precise P2Y12 monotherapy regimen warrant further investigation.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy.,Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico," Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Felicita Andreotti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
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22
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Rubboli A, Collet JP. Double vs. triple antithrombotic therapy in atrial fibrillation patients undergoing percutaneous coronary intervention: does clinical presentation matter? EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f61-f62. [PMID: 33247917 DOI: 10.1093/ehjcvp/pvaa121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Viale Randi 5, 48121, Ravenna, Italy
| | - Jean-Philippe Collet
- Sorbonne Universitè, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hopital Pitiè-Salpetriere (Assistance Publique-Hopitaux de Paris) (AP-HP), 83 Boulevard de l'Hopital, 75013, Paris, France
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23
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Gargiulo G, Cannon CP, Gibson CM, Goette A, Lopes RD, Oldgren J, Korjian S, Windecker S, Esposito G, Vranckx P, Valgimigli M. Safety and efficacy of double vs. triple antithrombotic therapy in patients with atrial fibrillation with or without acute coronary syndrome undergoing percutaneous coronary intervention: a collaborative meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:f50-f60. [PMID: 33119069 PMCID: PMC8117456 DOI: 10.1093/ehjcvp/pvaa116] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/10/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022]
Abstract
Aims Safety and efficacy of antithrombotic regimens in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) may differ based on clinical presentation. We sought to compare double vs. triple antithrombotic therapy (DAT vs. TAT) in AF patients with or without acute coronary syndrome (ACS) undergoing 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. Data on subgroups of ACS or elective PCI were obtained by published reports or trial investigators. A total of 10 193 patients from four NOAC trials were analysed, of whom 5675 presenting with ACS (DAT = 3063 vs. TAT = 2612) and 4518 with stable coronary artery disease (SCAD; DAT = 2421 vs. TAT = 2097). The primary safety endpoint of ISTH major bleeding or clinically relevant non-major bleeding was reduced with DAT compared with TAT in both ACS (12.2% vs. 19.4%; RR 0.63, 95% CI 0.56–0.71; P < 0.0001; I2 = 0%) and SCAD (14.6% vs. 22.0%; RR 0.68, 95% CI 0.55–0.85; P = 0.0008; I2 = 66%), without interaction (P-int = 0.54). Findings were consistent for secondary bleeding endpoints, including intra-cranial haemorrhage. In both subgroups, there was no difference between DAT and TAT for all-cause death, major adverse cardiovascular events, or stroke. Myocardial infarction and stent thrombosis were numerically higher with DAT vs. TAT consistently in ACS and SCAD (P-int = 0.60 and 0.86, respectively). Findings were confirmed by multiple sensitivity analyses, including a separate analysis on dabigatran regimens and a restriction to PCI population. Conclusions DAT, compared with TAT, is associated with lower bleeding risks, including intra-cranial haemorrhage, and a small non-significant excess of cardiac ischaemic events in both patients with or without ACS.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Heart and Vascular Center and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Baim Institute for Clinical Research, 930-W Commonwealth Avenue, Boston, MA 02215, USA
| | - Charles Michael Gibson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andreas Goette
- St. Vincenz-Hospital, Am Busdorf 2, 33098 Paderborn, Germany.,Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany.,Atrial Fibrillation Network (AFNET), Mendel Str.11, 48149 Münster, Germany
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, Durham, NC 27701, USA
| | - Jonas Oldgren
- Uppsala Clinical Research Center and, Department of Medical Sciences, Uppsala University, Dag Hammarskjolds vag 38, SE-751 85 Uppsala, Sweden
| | - Serge Korjian
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3030 Bern, Switzerland
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences, Hasselt University, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3030 Bern, Switzerland
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24
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Clinical risk predictors in atrial fibrillation patients following successful coronary stenting: ENTRUST-AF PCI sub-analysis. Clin Res Cardiol 2020; 110:831-840. [PMID: 33098470 PMCID: PMC8166657 DOI: 10.1007/s00392-020-01760-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/07/2020] [Indexed: 11/16/2022]
Abstract
Aims This subgroup analysis of the ENTRUST-AF PCI trial (ClinicalTrials.gov Identifier: NCT02866175; Date of registration: August 2016) evaluated type of AF, and CHA2DS2-VASc score parameters as predictors for clinical outcome. Methods Patients were randomly assigned after percutaneous coronary intervention (PCI) to either edoxaban (60 mg/30 mg once daily [OD]; n = 751) plus a P2Y12 inhibitor for 12 months or a vitamin K antagonist [VKA] (n = 755) plus a P2Y12 inhibitor and aspirin (100 mg OD, for 1–12 months). The primary outcome was a composite of major/clinically relevant non-major bleeding (CRNM) within 12 months. The composite efficacy endpoint consisted of cardiovascular death, stroke, systemic embolic events, myocardial infarction (MI), and definite stent thrombosis. Results Major/CRNM bleeding event rates were 20.7%/year and 25.6%/year with edoxaban and warfarin, respectively (HR [95% CI]: 0.83 [0.654–1.047]). The event rates of composite outcome were 7.26%/year and 6.86%/year, respectively (HR [95% CI]): 1.06 [0.711–1.587]), and of overall net clinical benefit were 12.48%/year and 12.80%/year, respectively (HR [(95% CI]: 0.99 [(0.730; 1.343]). Increasing CHA2DS2-VASc score was associated with increased rates of all outcomes. CHA2DS2-VASc score ≥ 5 was a marker for stent thrombosis. Paroxysmal AF was associated with a higher occurrence of MI (4.87% versus 2.01%, p = 0.0024). Conclusion After PCI in AF patients, increasing CHA2DS2-VASc score was associated with increased bleeding rates and CHA2DS2-VASc score (≥ 5) predicted the occurrence of stent thrombosis. Paroxysmal AF was associated with MI. These findings may have important clinical implications in AF patients.
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