Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting

Comparative Safety and Efficacy of Eight Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Background

Antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention is facing major treatment problems in clinical practice.

Methods

We firstly conducted a Bayesian network meta-analysis to study the safety and efficacy of different antithrombotic regimens. Only randomized controlled trials from PubMed, Web of Science, Cochrane Central Register of Controlled Trials, Embase, and China National Knowledge Infrastructure were included in our study. The Bayesian random-effects model was used in this study. The primary safety and efficacy outcomes were major bleeding according to the criteria of Thrombolysis In Myocardial Infarction (TIMI) and trial-defined major adverse cardiovascular events, respectively. The secondary safety outcomes were combined TIMI major and minor bleeding, trial-defined primary bleeding events, and intracranial hemorrhage. The secondary efficacy outcomes were all-cause or cardiovascular mortality, myocardial infarction, stroke, stent thrombosis, and hospitalization.

Results

Total of 11,532 patients from the five randomized controlled trials were analyzed, of whom 8,426 were male. Compared with vitamin K antagonist (VKA) plus P2Y12 inhibitor, the odds ratios (95% credible intervals) for TIMI major bleeding were 1.70 (0.77–3.80) for VKA plus dual antiplatelet therapy (DAPT), 1.20 (0.30–4.60) for rivaroxaban plus P2Y12 inhibitor, 1.00 (0.25–3.90) for rivaroxaban plus DAPT, 0.76 (0.21–2.80) for dabigatran plus P2Y12 inhibitor, 0.71 (0.25–2.10) for apixaban plus P2Y12 inhibitor, 1.40 (0.52–3.80) for apixaban plus DAPT, and 1.00 (0.27–4.00) for edoxaban plus P2Y12 inhibitor. For trial-defined major adverse cardiovascular events, compared with VKA plus P2Y12 inhibitor, the odds ratios (95% credible intervals) were 1.10 (0.61–2.00) for VKA plus DAPT, 1.20 (0.45–3.70) for rivaroxaban plus P2Y12 inhibitor, 1.10 (0.38–3.20) for rivaroxaban plus DAPT, 1.10 (0.43–3.10) for dabigatran plus P2Y12 inhibitor, 1.00 (0.47–2.20) for apixaban plus P2Y12 inhibitor, 0.99 (0.46–2.20) for apixaban plus DAPT, and 1.20 (0.43–3.40) for edoxaban plus P2Y12 inhibitor. Apixaban plus P2Y12 inhibitor was the highest-ranking of safety outcomes and VKA plus P2Y12 inhibitor was the highest-ranking of efficacy outcomes other than trial-defined major adverse cardiovascular events.

Conclusion

Apixaban plus P2Y12 inhibitor seems to be linked with fewer bleeding complications while retaining antithrombotic efficacy. Moreover, for most efficacy indicators, the ranking of VKA plus P2Y12 inhibitor is still very high.

Systematic Review Registration

[www.crd.york.ac.uk/prospero/], identifier [CRD42020149894].

Randomised controlled trial to investigate optimal antithrombotic therapy in patients with non-valvular atrial fibrillation undergoing percutaneous coronary intervention: a study protocol of the OPTIMA-AF trial

INTRODUCTION

The optimal antithrombotic strategy for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is uncertain. For patients with non-AF, many trials are now evaluating short 1-month dual antiplatelet therapy. In patients with AF undergoing PCI, in contrast, short dual therapy (P2Y₁₂ inhibitor +direct oral anticoagulant (DOAC)) has not yet been evaluated.

METHODS AND ANALYSIS

The OPTIMA-AF trial (OPTIMAl antiplatelet therapy in combination with direct oral anticoagulants in patients with non-valvular Atrial Fibrillation undergoing percutaneous coronary intervention with everolimus-eluting stent) is an investigator-initiated, open-label, nationwide, multicentre, prospective, randomised controlled trial. The primary objective is to compare the efficacy and safety of short dual therapy (1-month DOAC +P2Y₁₂ inhibitor followed by DOAC monotherapy) against long dual therapy (12-month DOAC +P2Y₁₂ inhibitor followed by DOAC monotherapy) in the treatment of AF subjects undergoing PCI. The primary efficacy endpoint is a composite of death or thromboembolic events (myocardial infarction, definite stent thrombosis, stroke or systemic embolism) at 365 days; and the primary safety endpoint is bleeding (International Society on Thrombosis and Haemostasis major or clinically relevant non-major bleeding) at 365 days. This trial is intended to show the non-inferiority of short dual therapy versus long dual therapy in terms of the primary efficacy endpoint and show superiority in terms of the primary safety endpoint. A total of 1090 subjects will be randomised in a 1:1 ratio at approximately 60 sites.

ETHICS AND DISSEMINATION

This study received approval from the Certified Review Board of Osaka University (a certified research ethics committee by the Japanese Clinical Research Act). The findings will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

Japan Registry of Clinical Trials: jRCTs051190053; Pre-results.

Echocardiographic risk factors of left ventricular thrombus in patients with acute anterior myocardial infarction

AIMS

This study aimed to identify echocardiographic determinants of left ventricular thrombus (LVT) formation after acute anterior myocardial infarction (MI).

METHODS AND RESULTS

This case-control study comprised 55 acute anterior MI patients with LVT as cases and 55 acute anterior MI patients without LVT as controls, who were selected from a cohort of consecutive patients with ischemic heart failure in our hospital. The cases and controls were matched for age, sex, and left ventricular ejection fraction. LVT was detected by routine/contrast echocardiography or cardiac magnetic resonance imaging during the first 3 months following MI. Formation of apical aneurysm after MI was independently associated with LVT formation [72.0% vs. 43.5%, odds ratio (OR) = 5.06, 95% confidence interval (CI) 1.65-15.48, P = 0.005]. Echocardiographic risk factors associated with LVT formation included reduced mitral annular plane systolic excursion (<7 mm, OR = 4.69, 95% CI 1.84-11.95, P = 0.001), moderate-severe diastolic dysfunction (OR = 2.71, 95% CI 1.11-6.57, P = 0.028), and right ventricular (RV) dysfunction [reduced tricuspid annular plane systolic excursion < 17 mm (OR = 5.48, 95% CI 2.12-14.13, P < 0.001), reduced RV fractional area change < 0.35 (OR = 3.32, 95% CI 1.20-9.18, P = 0.021), and enlarged RV mid diameter (per 5 mm increase OR = 1.62, 95% CI 1.12-2.34, P = 0.010)]. Reduced tricuspid annular plane systolic excursion (<17 mm) significantly associated with increased risk of LVT in anterior MI patients (OR = 3.84, 95% CI 1.37-10.75, P = 0.010), especially in those patients without apical aneurysm (OR = 5.12, 95% CI 1.45-18.08, P = 0.011), independent of body mass index, hypertension, anaemia, mitral annular plane systolic excursion, and moderate-severe diastolic dysfunction.

CONCLUSIONS

Right ventricular dysfunction as determined by reduced TAPSE or RV fractional area change is independently associated with LVT formation in acute anterior MI patients, especially in the setting of MI patients without the formation of an apical aneurysm. This study suggests that besides assessment of left ventricular abnormalities, assessment of concomitant RV dysfunction is of importance on risk stratification of LVT formation in patients with acute anterior MI.

Abbreviated Antiplatelet Therapy in Patients at High Bleeding Risk With or Without Oral Anticoagulant Therapy After Coronary Stenting: An Open-Label, Randomized, Controlled Trial

Supplemental Digital Content is available in the text.

The optimal duration of antiplatelet therapy (APT) in patients at high bleeding risk with or without oral anticoagulation (OAC) after coronary stenting remains unclear.

Drug Delivery With Carbon-Based Nanomaterials as Versatile Nanocarriers: Progress and Prospects

With growing interest, a large number of researches have been conducted on carbon-based nanomaterials (CBNs). However, their uses are limited due to comprehensive potential environmental and human health effects. It is often confusing for researchers to make an informed choice regarding the versatile carbon-based nanocarrier system and its potential applications. This review has highlighted emerging applications and cutting-edge progress of CBNs in drug delivery. Some critical factors like enzymatic degradation, surface modification, biological interactions, and bio-corona have been discussed here. These factors will help to fabricate CBNs for effective drug delivery. This review also addresses recent advancements in carbon-based target specific and release controlled drug delivery to improve disease treatment. The scientific community has turned their research efforts into the development of novel production methods of CBNs to make their production more attractive to the industrial sector. Due to the nanosize and diversified physical properties, these CBNs have demonstrated distinct biological interaction. Thus long-term preclinical toxicity study is recommended before finally translating to clinical application.

Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Network Meta-analysis of Randomized Controlled Trials

Importance

The antithrombotic treatment of patients with atrial fibrillation (AF) and coronary artery disease, in particular with acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI), poses a significant treatment dilemma in clinical practice.

Objective

To study the safety and efficacy of different antithrombotic regimens using a network meta-analysis of randomized controlled trials in this population.

Data Sources

PubMed, EMBASE, EBSCO, and Cochrane databases were searched to identify randomized controlled trials comparing antithrombotic regimens.

Study Selection

Four randomized studies were included (n = 10 026; WOEST, PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS).

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review and network meta-analysis between 4 regimens using a Bayesian random-effects model. A pre hoc statistical analysis plan was written, and the review protocol was registered at PROSPERO. Data were analyzed between November 2018 and February 2019.

Main Outcomes and Measures

The primary safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding; secondary safety outcomes were combined TIMI major and minor bleeding, trial-defined primary bleeding events, intracranial hemorrhage, and hospitalization. The primary efficacy outcome was trial-defined major adverse cardiovascular events (MACE); secondary efficacy outcomes were individual components of MACE.

Results

The overall prevalence of ACS varied from 28% to 61%. The mean age ranged from 70 to 72 years; 20% to 29% of the trial population were women; and most patients were at high risk for thromboembolic and bleeding events. Compared with a regimen of vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT; P2Y12 inhibitor plus aspirin), the odds ratios (ORs) for TIMI major bleeding were 0.58 (95% CI, 0.31-1.08) for VKA plus P2Y12 inhibitor, 0.49 (95% CI, 0.30-0.82) for non-VKA oral anticoagulant (NOAC) plus P2Y12 inhibitor, and 0.70 (95% CI, 0.38-1.23) for NOAC plus DAPT. Compared with VKA plus DAPT, the ORs for MACE were 0.96 (95% CI, 0.60-1.46) for VKA plus P2Y12 inhibitor, 1.02 (95% CI, 0.71-1.47) for NOAC plus P2Y12 inhibitor, and 0.94 (95% CI, 0.60-1.45) for NOAC plus DAPT.

Conclusions and Relevance

A regimen of NOACs plus P2Y12 inhibitor was associated with less bleeding compared with VKAs plus DAPT. Strategies omitting aspirin caused less bleeding, including intracranial bleeding, without significant difference in MACE, compared with strategies including aspirin. Our results support the use of NOAC plus P2Y12 inhibitor as the preferred regimen post-percutaneous coronary intervention for these high-risk patients with AF. A regimen of VKA plus DAPT should generally be avoided.

Clinical Outcomes of Antithrombotic Strategies for Patients with Atrial Fibrillation After Percutaneous Coronary Intervention

Antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) remain challenging. This study aims to explore the best antithrombotic strategy for AF patients after PCI based on a network meta-analysis. This study was registered in PROSPERO (CRD42018093928). The PubMed, Cochrane, and EMBASE databases were searched to identify clinical trials concerning antithrombotic therapy for AF patients with PCI from inception to April 2018. Pairwise and network meta-analysis were conducted to compare clinical outcomes of different antithrombotic therapy. The primary endpoint was major bleeding. Fifteen studies including 16,382 patients were identified with follow-up ranging from 3 to 12 months. Non-vitamin K oral anticoagulants (NOAC) plus P2Y₁₂ inhibitor ranked first with a reduced risk of major bleeding compared with vitamin K antagonist (VKA) plus dual antiplatelet therapy (OR: 0.57, 95% CI: 0.43-0.75) but with no significant difference compared with VKA plus single platelet therapy (OR: 0.85, 95% CI: 0.62-1.16). Similar thrombotic events were evident among these groups. Subgroup analysis showed that VKA plus aspirin exhibited a similar risk of major bleeding compared with VKA plus clopidogrel (OR: 0.94, 95% CI: 0.73-1.23) but was associated with increased risks of ischaemic stroke (OR: 2.10, 95% CI: 1.33-3.32) and all-cause death (OR: 1.77, 95% CI: 1.15-2.74) versus VKA plus clopidogrel. In AF patients undergoing PCI, NOAC plus P2Y₁₂ inhibitor and VKA plus clopidogrel, but not VKA plus aspirin, were associated with reduced risk of major bleeding compared with the recommended VKA-based triple therapy, while thrombotic events were similar among these treatments.

Bleeding Risk of Add-On Anti-Platelet Agents to Direct Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation (From 2216 Patients in the DIRECT Registry)

Clinical outcomes of the real-world Asian nonvalvular atrial fibrillation (NVAF) patients treated with DOAC and the incremental bleeding risk of add-on antiplatelet therapy to direct oral anticoagulants (DOACs) are still to be investigated. We conducted a single-center prospective observational registry of NVAF patients treated with DOACs: the DIRECT registry (UMIN000033283). All patients with NVAF (N = 2216) who were users of dabigatran (N = 648), rivaroxaban (N = 538), apixaban (N = 599), or edoxaban (N = 431) from June 2011 to November 2017 were enrolled (71.6 ± 10.8 years, 36.4% female, follow-up duration: 407.2 ± 388.3 days). No add-on antiplatelet agent was prescribed to 1,739 patients, while single and dual antiplatelet therapy (SAPT and DAPT) in combination with DOAC were prescribed to 411 and 66 patients, respectively. The primary safety endpoint was any bleeding which was defined as a composite of major bleeding according to the International Society on Thrombosis and Hemostasis criteria and clinically relevant non-major bleeding. Patients treated with add-on antiplatelet agents irrespective of SAPT or DAPT had a higher any-bleeding risk than those without (hazard ratio: 1.42; 95% confidence interval 1.16-1.74, p = 0.001). Multivariate adjusted hazard of add-on antiplatelet therapy was not statistically significant (hazard ratio: 1.20; 95% confidence interval 0.94-1.53, p = 0.147). In conclusion, NVAF patients treated with antiplatelet agents and DOAC had a significantly higher bleeding risk than those using DOAC only. However, after adjustment of patients' background, add-on antiplatelet therapy to DOAC itself did not influence to a bleeding risk.

Relationship of left ventricular thrombus formation and adverse outcomes in acute anterior myocardial infarction in patients treated with primary percutaneous coronary intervention

BACKGROUND

The incidence of left ventricular thrombus (LVT) is 4% to 15% in patients with anterior acute ST-segment elevation myocardial infarction (ant-AMI) in the era of primary percutaneous coronary intervention (PPCI). And patients with LVT have higher in-hospital mortality.

HYPOTHESIS

There is a relationship between LVT formation and 1-year major adverse cardio-cerebrovascular events (MACCE) in patients with ant-AMI treated by PPCI.

METHODS

Our study population included 1488 consecutive patients with ant-AMI. The primary endpoint was the incidence of MACCE within 1 year after AMI. The secondary endpoint was the thrombosis disappearance.

RESULTS

A total of 106 (7.1%) patients were diagnosed with LVT and 1382 (92.9%) patients without LVT. Patients with LVT had a higher incidence of MACCE than in patients without LVT (21.7%vs10.3%; P < 0.001). Univariate analysis showed LVT was associated with an increase in MACCE risk (odds ratio [OR] = 2.40; 95% confidence interval [CI] [1.37-4.21]; P < 0.001). When examining MACCE components individually, LVT was only associated with the incidence of congestive heart failure (OR = 2.41; 95% CI [1.29-4.58]; P = 0.001). After adjustment for principal confounders, LVT remained an independent risk factor for MACCE (HR = 2.28; 95% CI [1.12-6.38]; P = 0.020). Other independent predictors include 24-hour LVEF, creatine kinase peak value, and age. Further analysis found patients with LVT in international normalized ratio (INR) ≥ 2 group had lower MACCE risk and higher thrombus disappearance than in INR < 2 group (13.5%vs29.6%; P = 0.044; 90.4%vs74.1%; P = 0.029).

CONCLUSION

For patients with ant-AMI treated by PPCI, LVT is an independent predictor of 1-year MACCE events. Treatment with vitamin K antagonist in the therapeutic range (INR ≥ 2) has the potential to reduce MACCE risk and promote disappearance of thrombus.

Oral anticoagulant use in cardiovascular disorders: a perspective on present and potential indications for rivaroxaban

BACKGROUND

Four non-vitamin-K-antagonist oral anticoagulants (NOACs) have been approved for use in various cardiovascular indications. The direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors apixaban, edoxaban and rivaroxaban are now increasingly used in clinical practice. For some of these agents, available data from real-world studies support the efficacy and safety data in phase III clinical trials.

OBJECTIVES

This review aims to summarize the current status of trials and observational studies of oral anticoagulant use over the spectrum of cardiovascular disorders (excluding venous thrombosis), provide a reference source beyond stroke prevention for atrial fibrillation (AF) and examine the potential for novel applications in the cardiovascular field.

METHODS

We searched the recent literature for data on completed and upcoming trials of oral anticoagulants with a particular focus on rivaroxaban.

RESULTS

Recent data in specific patient subgroups, such as patients with AF undergoing catheter ablation or cardioversion, have led to an extended approval for rivaroxaban, whereas the other NOACs have ongoing or recently completed trials in this setting. However, there are unmet medical needs for several arterial thromboembolic-related conditions, including patients with: AF and acute coronary syndrome, AF and coronary artery disease undergoing elective percutaneous coronary intervention, coronary artery disease and peripheral artery disease, implanted cardiac devices, and embolic stroke of unknown source.

CONCLUSION

NOACs may provide alternative treatment options in areas of unmet need, and numerous studies are underway to assess their benefit-risk profiles in these settings.

Clinical effects with inhibition of multiple coagulative pathways in patients admitted for acute coronary syndrome

Platelets and the coagulation cascade play key roles in initiation, amplification, and perpetuation of acute coronary syndromes (ACS). In the past few years, there has been great progress in ACS antithrombotic treatment with the introduction of novel anticoagulants (fondaparinux and bivalirudin), more potent P2Y₁₂ inhibitors (prasugrel and ticagrelor) and protease-activated receptor antagonists (vorapaxar). Nonetheless, patients with ACS frequently have recurrent ischemic events despite the use of currently recommended dual antiplatelet therapy, revascularization procedures as appropriate, and other evidence-based secondary preventive measures. This is the rationale beyond intensification of antiplatelet therapy. However, the major downside of intensive antithrombotic therapy is bleeding. When treating ACS patients, clinicians should find the adequate balance between the reduction of thrombotic events by effective drug treatment and the induction of bleeding that is linked to the use of potent or multiple antithrombotic agents. Numerous antithrombotic cocktails including oral anticoagulants with or without aspirin have been tested in large clinical trials with the goal of further reduction of ischemia and bleeding risk. The aim of this review is to discuss clinical outcomes resulting from inhibition of multiple coagulative pathways in patients with ACS in light of evidence from large randomized controlled clinical trials.

Dual versus triple antithrombotic therapy after percutaneous coronary intervention or acute coronary syndrome in patients with indication for anticoagulation: an updated meta-analysis

BACKGROUND

For patients who have an indication for anticoagulation, it is controversial whether dual therapy with an oral anticoagulant and single antiplatelet agent can be used after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) instead of triple therapy with an oral anticoagulant and dual antiplatelet therapy.

PARTICIPANTS AND METHODS

Twelve observational studies and four clinical trials were identified from three electronic databases from their inception to December, 2017. Pooled estimates were calculated using a random-effects model for meta-analysis.

RESULTS

Compared with the triple therapy, dual therapy was associated with significantly lower risk of major bleeding [relative risk (RR), 0.63; 95% confidence interval (CI), 0.50-0.80] without statistically significant increase in major adverse cardiac events (RR, 1.04; 95% CI, 0.84-1.29), all-cause death (RR, 1.15; 95% CI, 0.77-1.71), cardiac death (RR, 1.04; 95% CI, 0.67-1.61), myocardial infarction (RR, 1.25; 95% CI, 0.98-1.59), stroke (RR, 1.27; 95% CI, 0.79-2.06), stent thrombosis (RR, 1.52; 95% CI, 0.96-2.41), and repeat revascularization (RR, 1.15; 95% CI, 0.87-1.52). Although risks of myocardial infarction and stent thrombosis were marginally higher in the dual therapy group, this trend was attenuated after excluding studies that exclusively included patients undergoing PCI for ACS, but not stable coronary artery disease.

CONCLUSION

Dual therapy may be a reasonable alternative to triple therapy after PCI in patients with indication for chronic anticoagulation. However, further studies are needed to investigate efficacy of dual therapy, especially in the patients with higher ischemic risk, such as in ACS.

Dual versus triple therapy in patients on oral anticoagulants and undergoing coronary stent implantation: A systematic review and meta-analysis

BACKGROUND AND AIMS

There is contrasting evidence regarding the optimal antithrombotic regimen after percutaneous coronary stent implantation in patients on oral anticoagulants. A systematic review and meta-analysis was performed to explore the comparative efficacy and safety of dual (an antiplatelet plus an oral anticoagulant) versus triple therapy (dual antiplatelet therapy plus an oral anticoagulant).

METHODS

We searched the literature for randomized controlled trials (RCTs) or observational studies (OSs) addressing this issue. The efficacy outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction and stent thrombosis. The safety outcomes were major bleeding events and all bleeding events. The analyses were stratified by type of anticoagulant and of antiplatelet used in dual therapy.

RESULTS

Four RCTs and ten OSs met our inclusion criteria including a total of 10,126 patients. 5671 patients received triple therapy whereas 4455 received dual therapy. Median follow up was 12 months. There was no difference between dual therapy and triple therapy regarding efficacy outcomes. Dual therapy significantly reduced the risk of major bleeding (RR 0.66; CI 95% 0.52-0.83; P = 0.0005) and of all bleeding events (RR 0.67, CI 95% 0.55-0.80; P < 0.0001). The effect was consistent regardless of the type of antiplatelet and anticoagulant used in dual therapy.

CONCLUSION

Dual antithrombotic therapy after coronary stenting in anticoagulated patients significantly reduces bleeding events compared with triple therapy. Dual therapy might be considered in this setting especially when bleeding risk outweighs ischemic risk, although our study was not sufficiently powered to detect a difference in ischemic endpoints.

Vasodilator-stimulated phosphoprotein-guided Clopidogrel maintenance therapy reduces cardiovascular events in atrial fibrillation patients requiring anticoagulation therapy and scheduled for percutaneous coronary intervention: a prospective cohort study

BACKGROUND

In a previous study, we found that titrating clopidogrel maintenance doses (MDs) according to vasodilator-stimulated phosphoprotein (VASP) monitoring minimised the rate of major adverse cardiovascular and cerebral events (MACCE) after percutaneous coronary intervention (PCI) without increasing bleeding in patients with high on-treatment platelet reaction to clopidogrel. This study aimed to investigate whether VASP-guided clopidogrel MD could reduce thromboembolism and bleeding in atrial fibrillation (AF) patients requiring anticoagulation and scheduled for PCI.

METHODS

AF patients scheduled for PCI were recruited between July 2014 and July 2016. These patients were allocated into VASP-guided (n = 250) and control (n = 253) groups depending on the clopidogrel MD profile. In the VASP-guided group, clopidogrel MD was titrated by the platelet reactivity index (PRI), whereas in the control group, clopidogrel MD was fixed at 75 mg per day. The primary endpoint was MACCE and secondary endpoints were thrombolysis in myocardial infarction (TIMI) major and minor bleeding 1 year after PCI.

RESULTS

Five hundred and three patients were included in the present study, with 1-year data available for 95.6% patients. The average CHA2DS2-VASc score of the whole population was 3.7 ± 0.7 and the average HAS-BLED score was 3.2 ± 0.4. MACCE was less in the VASP-guided group than in the control group (2.5% vs. 5.0%, P = 0.02). The incidence of major bleeding was comparable between both groups (3.0% vs. 2.8%, P = 0.72) and minor bleeding was higher in the VASP-guided group than in the control group (15.3% vs. 9.7%, P = 0.03). Kaplan-Meier analysis indicated that there was no difference in survival between both groups (log-rank test, P = 0.68).

CONCLUSIONS

In AF patients requiring anticoagulation and scheduled for PCI, VASP-guided antiplatelet therapy reduced major cardiovascular and cerebral adverse events, accompanied by increased minor bleeding events.

TRIAL REGISTRATION

The present study was retrospectively registered in the Chinese Clinical Trial Registry, A Primary Registry of the International Clinical Trial Registry Platform, World Health Organisation (Registration no: ChiCTR-IOR-17013854 ). The registered date was December 11, 2117.

Optimum Antithrombotic Therapy in Patients Requiring Long-Term Anticoagulation and Undergoing Percutaneous Coronary Intervention

Management of patients on long-term anticoagulation requiring percutaneous coronary intervention is challenging. Triple therapy with oral anticoagulant and dual antiplatelet therapy is the standard of care. However, there is no strong evidence to support this strategy. There is emerging data regarding the safety and efficacy of dual therapy with oral anticoagulant and single antiplatelet therapy in these patients. In this comprehensive review we highlight available evidence regarding various antithrombotic regimens' efficacy and safety in patient with coronary artery disease undergoing percutaneous coronary intervention with long-term anticoagulation therapy requirements.

Contemporary approach to stroke prevention in atrial fibrillation: Risks, benefits, and new options

Atrial fibrillation is a common diagnosis affecting nearly 3 million adults in the United States. Morbidity and mortality in these patients is driven largely by the associated increased risk of thromboembolic complications, especially stroke. Atrial fibrillation is a stronger risk factor than hypertension, coronary disease, or heart failure and is associated with an approximately five-fold increased risk. Mitigating stroke risk can be challenging and requires accurate assessment of stroke risk factors and careful selection of appropriate therapy. Anticoagulation, including the more recently introduced direct oral anticoagulants, is the standard of care for most patients. In addition, emerging non-pharmacologic mechanical interventions are playing an expanding role in reducing stroke risk in select patients. In this review we highlight the current approach to stroke risk stratification in atrial fibrillation and discuss in detail the mechanism, risks, and benefits of current and evolving therapies.

Dual Antithrombotic Therapy with Clopidogrel and Novel Oral Anticoagulants in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Real-world Study

Introduction

For patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), proper antithrombotic therapy is equivocal. Current guidelines recommend triple therapy, which carries a high risk of bleeding. Recent large trials suggest that dual therapy (DT) with novel oral anticoagulant (NOAC) plus P2Y₁₂ inhibitor can be an appropriate alternative, but real-world data for this alternative are scarce and the optimal duration of DT has not yet been established.

Methods

This analysis was performed in a single-center prospective cohort. We investigated 216 PCI patients with indication for anticoagulation due to AF. After PCI patients received DT with reduced doses NOAC plus P2Y₁₂ inhibitor for 6 months, which was followed by standard dose NOAC monotherapy. Efficacy endpoints were defined as cardiac death, myocardial infarction (MI), stent thrombosis (ST), and stroke. Safety endpoints were bleeding events as defined by Bleeding Academic Consortium (BARC).

Results

Baseline characteristics of our study population were described by a CHA₂DS₂-VASc score of greater than 4 and a HAS-BLED score of greater than 3. After a mean follow-up of 18.7 months, efficacy events occurred in 12 patients (5.6%). We observed three (1.4%) cardiac deaths, two (0.9%) MIs, six (2.8%) strokes, and one (0.5%) definite ST. After switching from DT to NOAC monotherapy after 6.3 ± 1.7 months, there was no rebound of ischemic events. Bleeding events occurred in 34 patients (15.7%) mainly under DT, while bleeding was less during NOAC monotherapy.

Conclusions

In this long-term study of high-risk and real-world AF-patients with PCI, DT with NOAC and P2Y₁₂ inhibitor (6 months) followed by NOAC monotherapy was safe and effective.

Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: Where Are We Now?

OBJECTIVE

To synthesize the literature and provide guidance to practitioners regarding double therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) requiring percutaneous coronary intervention (PCI).

DATA SOURCES

PubMed and MEDLINE (January 2000 to February 2018) were searched using the following terms: atrial fibrillation, myocardial infarction, acute coronary syndrome, percutaneous coronary intervention, anticoagulation, dual-antiplatelet therapy, clopidogrel, aspirin, ticagrelor, prasugrel, and triple therapy.

STUDY SELECTION AND DATA EXTRACTION

The results included randomized and nonrandomized clinical trials and meta-analyses. Each study was reported based on study design, population, intervention, comparator, and key cardiovascular (CV) and bleeding outcomes.

DATA SYNTHESIS

A total of 15 studies were included in the review. The majority of studies evaluating DT and TT utilized clopidogrel and warfarin as components of the regimen, although there are emerging data with newer agents. Evidence purporting DT regimens to be equally effective in preventing CV events and improved safety profiles compared with TT regimens included populations with relatively low risk for recurrent CV events, and many of these studies were observational in nature. Overall, current evidence as well as American and European guidelines support the use of TT in patients with AF who require PCI for the least possible amount of time, depending on patient-specific factors involving bleeding and thrombosis.

CONCLUSIONS

In the majority of patients with AF who require PCI, TT should be used for the shortest period of time possible. DT regimens may be used in patients requiring PCI who have low risk for thrombosis and/or high bleeding risk.

Percutaneous coronary intervention and antiplatelet therapy in patients with atrial fibrillation receiving apixaban or warfarin: Insights from the ARISTOTLE trial

BACKGROUND

We assessed antiplatelet therapy use and outcomes in patients undergoing percutaneous coronary intervention (PCI) during the ARISTOTLE trial.

METHODS

Patients were categorized based on the occurrence of PCI during follow-up (median 1.8 years); PCI details and outcomes post-PCI are reported. Of the 18,201 trial participants, 316 (1.7%) underwent PCI (152 in apixaban group, 164 in warfarin group).

RESULTS

At the time of PCI, 84% (267) were on study drug (either apixaban or warfarin). Of these, 19% did not stop study drug during PCI, 49% stopped and restarted <5 days post-PCI, and 30% stopped and restarted >5 days post-PCI. At 30 days post-PCI, 35% of patients received dual -antiplatelet therapy (DAPT), 23% received aspirin only, and 13% received a P2Y₁₂ inhibitor only; 29% received no antiplatelet therapy. Triple therapy (DAPT + oral anticoagulant [OAC]) was used in 21% of patients, 23% received OAC only, 15% received OAC plus aspirin, and 9% received OAC plus a P2Y₁₂ inhibitor; 32% received antiplatelet agents without OAC. Post-PCI, patients assigned to apixaban versus warfarin had numerically similar rates of major bleeding (5.93 vs 6.73 events/100 patient-years; P = .95) and stroke (2.74 vs 1.84 events/100 patient-years; P = .62).

CONCLUSIONS

PCI occurred infrequently during follow-up. Most patients on study drug at the time of PCI remained on study drug in the peri-PCI period; 19% continued the study drug without interruption. Antiplatelet therapy use post-PCI was variable, although most patients received DAPT. Additional data are needed to guide the use of antithrombotics in patients undergoing PCI.

2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Focused Update of the Guidelines for the Use of Antiplatelet Therapy

Antiplatelet therapy (APT) has become an important tool in the treatment and prevention of atherosclerotic events, particularly those associated with coronary artery disease. A large evidence base has evolved regarding the relationship between APT prescription in various clinical contexts and risk/benefit relationships. The Guidelines Committee of the Canadian Cardiovascular Society and Canadian Association of Interventional Cardiology publishes regular updates of its recommendations, taking into consideration the most recent clinical evidence. The present update to the 2011 and 2013 Canadian Cardiovascular Society APT guidelines incorporates new evidence on how to optimize APT use, particularly in situations in which few to no data were previously available. The recommendations update focuses on the following primary topics: (1) the duration of dual APT (DAPT) in patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome and non-acute coronary syndrome indications; (2) management of DAPT in patients who undergo noncardiac surgery; (3) management of DAPT in patients who undergo elective and semiurgent coronary artery bypass graft surgery; (4) when and how to switch between different oral antiplatelet therapies; and (5) management of antiplatelet and anticoagulant therapy in patients who undergo PCI. For PCI patients, we specifically analyze the particular considerations in patients with atrial fibrillation, mechanical or bioprosthetic valves (including transcatheter aortic valve replacement), venous thromboembolic disease, and established left ventricular thrombus or possible left ventricular thrombus with reduced ejection fraction after ST-segment elevation myocardial infarction. In addition to specific recommendations, we provide values and preferences and practical tips to aid the practicing clinician in the day to day use of these important agents.

Antithrombotic treatment in patients undergoing transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) is an established treatment option for symptomatic patients with severe aortic valvular disease who are not suitable for conventional surgical aortic valve replacement. Despite improving experience and techniques, ischaemic and bleeding complications after TAVI remain prevalent and impair survival in this generally old and comorbid-rich population. Due to changing aetiology of complications over time, antiplatelet and anticoagulant therapy after TAVI should be carefully balanced. Empirically, a dual antiplatelet strategy is generally used after TAVI for patients without an indication for oral anticoagulation (OAC; e. g. atrial fibrillation, mechanical mitral valve prosthesis), including aspirin and a thienopyridine. For patients on OAC, a combination of OAC and aspirin or thienopyridine is generally used. This review shows that current registries are unfit to directly compare antithrombotic regimens. Small exploring studies suggest that additional clopidogrel after TAVI only affects bleeding and not ischemic complications. However, these studies are lack in quality in terms of Cochrane criteria. Currently, three randomised controlled trials are recruiting to gather more knowledge about the effects of clopidogrel after TAVI.

Anticoagulation in patients with atrial fibrillation undergoing coronary stent implantation

In patients with atrial fibrillation (AF) undergoing coronary stent implantation, the optimal antithrombotic strategy is unclear. We evaluated whether use of oral anticoagulation (OAC) was associated with any benefit in morbidity or mortality in patients with AF, high risk of thromboembolism (TE) (CHA2DS2-VASC score ≥2) and coronary stent implantation. Among 8,962 unselected patients with AF seen between 2000 and 2010, a total of 2,709 (30%) had coronary artery disease and 417/2,709 (15%) underwent stent implantation while having CHA2DS2-VASC score ≥2. During follow-up (median=650 days), all TE, bleeding episodes, and major adverse cardiac events (i.e. death, acute myocardial infarction, target lesion revascularisation) were recorded. At discharge, 97/417 patients (23%) received OAC, which was more likely to be prescribed in patients with permanent AF and in those treated for elective stent implantation. The incidence of outcome event rates was not significantly different in patients treated and those not treated with OAC. However, in multivariate analysis, the lack of OAC at discharge was independently associated with increased risk of death/stroke/systemic TE (relative risk [RR] =2.18, 95% confidence interval [CI] 1.02-4.67, p=0.04), with older age (RR =1.12, 1.04-1.20, p=0.003), heart failure (RR =3.26, 1.18-9.01, p=0.02), and history of stroke (RR =18.87, 3.11-111.11, p=0.001). In conclusion, in patients with AF and high thromboembolic risk after stent implantation, use of OAC was independently associated with decreased risk of subsequent death/stroke/systemic TE, suggesting that OAC should be systematically used in this patient population.

Mild kidney disease as a risk factor for major bleeding in patients with atrial fibrillation undergoing percutaneous coronary stenting

Bleeding risk is increased in patients with atrial fibrillation (AF) and moderate to severe kidney disease (KD); however, the implication of mild KD on bleeding remains unclear. The aim of this study was to determine whether the presence of mild KD increases risk for major bleeding (MB) in patients with AF undergoing percutaneous coronary intervention with stent implantation (PCI-S). Two hundred eighty-five patients were included. Patients were classified into three kidney function groups: moderate to severe KD (n=91; <60 ml/min/1.73 m2), mild KD (n=139; 60–89 ml/min/1.73 m2) and non-KD (n=55; ≥90 ml/min/1.73 m2). Estimated glomerular filtration rate was calculated using the simplified Modification of Diet in Renal Disease equation. Patients were followed for one year, and the occurrence of MB was obtained in all. A total of 28 patients (9.8%) presented MB. MB complications examined as a function of KD groups revealed that there was a graded increase in MB with worsening renal function (non KD=1.8%, mild KD=7.9%, moderate to severe KD=17.6%; p <0.001). Multivariable Cox regression analysis showed that mild KD was associated with nearly a 2.5-fold (2.43 95% confidence interval 1.11–5.34, p=0.039) increase in the risk of MB as compared with non-KD patients. Other independent predictors of MB were moderate-severe KD, anaemia and triple antithrombotic therapy after PCI-S (C-index=0.76). In this population, mild KD confers a significantly increase in the risk for MB complications. Future studies should assess the potential role of incorporating mild KD into the bleeding risk scales to improve the stratification of these patients.

Triple Antithrombotic Therapy and Outcomes in Post-PCI Patients Undergoing Non-cardiac Surgery

BACKGROUND

Triple therapy, or the use of anticoagulants with dual antiplatelet therapy (DAPT), is often used to protect against ischemic events in post-percutaneous coronary intervention (PCI) patients with indications for anticoagulation, but is associated with increased bleeding. As both ischemic and bleeding risks increase in the perioperative period, the impact of triple therapy may be especially pronounced in patients undergoing surgery. Outcomes in this population are currently unknown.

METHODS

We identified patients undergoing non-cardiac surgeries within 2 years of PCI in Veterans Affairs hospitals from 2004 to 2012. We compared perioperative major adverse cardiovascular and cerebrovascular events (MACCE: mortality, myocardial infarction, stroke, revascularization) and bleeding events (in-hospital bleeding, transfusion) between surgeries in patients prescribed triple therapy and DAPT, adjusting for clinical, demographic, and operative characteristics.

RESULTS

Among 7811 surgeries, 391 (5.0 %) occurred in patients receiving triple therapy. 44 (11.3 %) MACCE and 107 (27.4 %) bleeding events occurred with surgeries in triple therapy patients, compared to 366 (4.9 %) MACCE and 980 (13.2 %) bleeding events in DAPT patients. After adjustment, surgery in triple therapy patients was associated with higher rates of MACCE [odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.16-2.34] or bleeding (OR 1.52, 95 % CI 1.17-1.99) as compared to surgery in DAPT patients.

CONCLUSIONS

One in twenty post-PCI patients undergoing non-cardiac surgery were on triple therapy. Surgery in these patients was associated with higher MACCE and bleeding events compared to surgery in patients on DAPT, independent of clinical and operative characteristics. These findings identify a high-risk population for surgery, which may warrant increased surveillance for adverse perioperative events.

Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A North American Perspective-2016 Update

The optimal antithrombotic treatment regimen for patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation is an emerging clinical problem. Currently, there is limited evidenced-based data on the optimal antithrombotic treatment regimen, including antiplatelet and anticoagulant therapies, for these high-risk patients with practice guidelines, thus, providing limited recommendations. Over the past years, expert consensus documents have provided guidance to clinicians on how to manage patients with atrial fibrillation undergoing percutaneous coronary intervention. Given the recent advancements in the field, the current document provides an updated opinion of selected North American experts from the United States and Canada on the treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention. In particular, this document provides the current views on (1) embolic/stroke risk, (2) ischemic/thrombotic cardiac risk, and (3) bleeding risk, which are pivotal for discerning the choice of antithrombotic therapy. In addition, we describe the recent advances in pharmacology, stent designs, and clinical trials relevant to the field. Ultimately, we provide expert consensus-derived recommendations, using a pragmatic approach, on the management of patients with atrial fibrillation undergoing percutaneous coronary intervention.

Coronary artery stenosis treatment in aging patients with inherited Factor VII deficiency: Where do we stand?

Aging with rare bleeding disorders such as factor VII (FVII) deficiency poses several challenges to treatment because of the occurrence of cerebral and cardiovascular age-related comorbidities and high bleeding risks. We report a case of long-term treatment with antiplatelet agents and contemporary prophylaxis of bleeding in a woman affected by severe FVII deficiency diagnosed with symptomatic coronary artery stenosis. Information on the management of antithrombotic treatment in rare bleeding disorders is lacking and mainly limited to anecdotal reports or side effects secondary to replacement therapy. We also briefly reviewed available data on the treatment of arterial thrombosis in FVII deficiency.

Safety and Efficacy of Dual Versus Triple Antithrombotic Therapy in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Choosing an antithrombotic regimen after coronary intervention in patients with concomitant indication for anticoagulation is a challenge commonly encountered by clinicians.

METHODS

We performed a meta-analysis of observational studies and randomized, controlled trials comparing outcomes of triple therapy (dual antiplatelet therapy and anticoagulant) with dual therapy (single antiplatelet therapy and anticoagulant) in patients taking long-term anticoagulants after percutaneous coronary intervention. Major bleeding was the primary outcome. Random effects overall risk ratios (RRs) were calculated using the DerSimonian and Laird model.

RESULTS

Nine observational studies and 2 randomized controlled trials with a total of 7276 patients met our selection criteria. At a mean follow-up of 10.8 months major bleeding was higher in the triple therapy cohort compared with dual therapy (6.6% vs 3.8%; RR 1.54; 95% confidence interval [CI], 1.2-1.98; P <.01). No difference was observed between the 2 groups for all-cause mortality (RR 0.98; 95% CI, 0.68-1.43; P = .93), major adverse cardiac events (RR 1.03; 95% CI, 0.8-1.32; P = .83), thromboembolic events (RR 1.02; 95% CI, 0.49-2.10; P = .96), myocardial infarction (RR 0.85; 95% CI, 0.67-1.09; P = .21), stent thrombosis (RR 0.77; 95% CI, 0.46-1.3; P = .33), and target vessel revascularization (RR 0.87; 95% CI, 0.66-1.15; P = .33).

CONCLUSION

In patients receiving anticoagulant therapy, a strategy of single antiplatelet therapy confers a benefit of less major bleeding with no difference in all-cause mortality, cardiovascular mortality, major adverse cardiac events, myocardial infarction, stent thrombosis, or thromboembolic event rate compared with dual antiplatelet therapy.

The safety and efficacy of oral anticoagulants with dual versus single antiplatelet therapy in patients after percutaneous coronary intervention: A meta-analysis

BACKGROUND

A growing number of patients require oral anticoagulant (OAC) after undergoing percutaneous coronary intervention (PCI) with stent implantation due to the development of atrial fibrillation, but the optimal antithrombotic regimen remains controversial in these patients.

METHODS

We systematically searched PUBMED, EMBASE, and CENTRAL from inception until September 2016 for randomized controlled trials or cohort studies that evaluated the comparative effects of TT versus DT. Relative risks (RRs) with 95% confidence intervals (95% CIs) were pooled by a random-effects model or a fixed-effects model.

RESULTS

Twelve studies with a total of 30,823 patients were included in this analysis, including 6134 in the TT group and 24,689 in the DT group. No significant differences were found between the TT group and the DT group regarding major adverse cardiovascular events (MACE) (RR = 0.82, 95% CI: 0.58-1.17; I = 87.3%), stroke (RR = 1.08, 95% CI: 0.56-2.07; I = 65.5%), all-cause mortality (RR = 0.90, 95% CI: 0.54-1.51; I = 79.1%), or stent thrombosis (RR = 0.71, 95% CI: 0.41-1.24; I = 12.7%), and lower rates were observed for myocardial infarction (RR = 0.59, 95% CI: 0.50-0.70; I = 31.1%) and major bleeding with TT (RR = 0.86, 95% CI: 0.74-0.99; I = 24.3%). Meanwhile, we also found that compared with TT, OAC with clopidogrel treatment shows equal efficacy and safety outcomes.

CONCLUSION

In patients on OAC undergoing PCI with stent implantation, compared with DT, TT shows equal effectiveness in terms of MACE, stroke, all-cause mortality, and stent thrombosis and lower risks of myocardial infarction and major bleeding. However, similar efficacy and safety outcomes were observed between the TT group and the OAC along with clopidogrel group.

The successful use of autologous skin in management of guidewire-induced distal coronary perforation

The successful use of autologous skin to management may provide a useful and widely applicable method for dealing with the troublesome complication of guidewire‐induced coronary perforation.

Effects of dielectrophoresis on thrombogenesis in human whole blood

Thrombogenesis (blood clot formation) is a major barrier to the development of biomedical devices that interface with blood. Although state-of-the-art chemically and pharmacologically mediated clot mitigation strategies are effective, some limitations of such approaches include depletion of active agents, or adverse reactions in patients. Increased clotting protein adsorption and platelet adhesion, which occur when artificial surfaces are exposed to blood result in enhanced clot formation on artificial surfaces. It is hypothesized that repelling proteins and platelets using dielectrophoresis (DEP), a contact-free particle manipulation technique, will reduce clot formation in biomedical devices. In this paper, the effect of DEP on thrombogenesis in human blood is investigated. Undiluted whole blood from human donors is pumped through microchannels at a physiological shear rate (400 s^-1 ). Experiments are performed by applying 0 V, 0.5 V_rms , 2 V_rms , and 3 V_rms to electrodes in the channel. Clot formation is observed to decrease in experiments in which DEP electrodes are active (average of 6% coverage @ 0V reduced to 0.08% coverage @ 3 V_rms ). Repulsion is more effective at higher voltages. DEP causes a quantifiable reduction in microscopic and macroscopic clot formation in PDMS microchannels.

Safety and efficacy of anti-thrombotic regimens in patients with percutaneous coronary intervention requiring oral anticoagulation: A traditional and network meta-analysis

BACKGROUND

Previous reports have been inconsistent in generating a consensus for optimal treatment strategy for patients with percutaneous coronary intervention (PCI) who also require oral anticoagulation (OAC). We conducted a traditional and network meta-analysis to evaluate the safety and efficacy of anti-thrombotic regimens in this subset of patients.

METHODS

30 articles were recovered through preferred reporting items for systematic reviews and meta-analyses (PRISMA) using MEDLINE, EMBASE and Cochrane Central Register of Controlled Clinical Trials (CENTRAL) from inception to December 2016.

RESULTS

Dual antiplatelet therapy (DAPT) was found to be the safest treatment modality when compared to triple therapy (TT) or combination of OAC and single antiplatelet agent (OAC+SAP) [Major bleeding: (DAPT vs OAC+SAP: odds ratio (OR), 0.53; 95% credible interval (CrI), 0.30-0.91) (DAPT vs TT: OR, 0.45; 95% CrI, 0.31-0.64)]. There were no significant differences in major adverse cardiovascular events (MACE), myocardial infarction (MI), cardiovascular (CV) or total survival, stent thrombosis or target vessel revascularization (TVR) amongst the three treatment arms. TT was ranked superior for stroke reduction (SUCRA, 69%) followed by OAC+SAP and DAPT. When traditional analysis was adjusted for randomized data, OAC+SAP was equivalent to TT with regards to stroke (OR, 0.74; 95% confidence interval (CI), 0.38-1.46; p=0.39) and showed significant reduction in MACE and total mortality.

CONCLUSION

DAPT was found to be the safest and equally effective regimen when compared to TT and OAC+SAP. However this strategy bears considerable risk to patients with high thromboembolic risk. This issue can be encountered by using OAC+SAP as an alternative of TT in patients with intermediate to high stroke risk and intermediate to high bleeding propensity.

Risk and Benefits of Triple Therapy in Patients Undergoing Coronary Stent Implantation Requiring Oral Anticoagulation: A Meta-Analysis of 16 Studies

BACKGROUND

Patients with coronary artery disease who undergo stent implantation and have concomitant indication for long-term oral anticoagulation represent a considerable proportion of the overall population. To date there is still no consensus about the optimal antithrombotic strategy to choose in this kind of patients, due to the difficult balance between an increased risk of bleeding and thromboembolic complications. Therefore, the aim of this study was to perform a meta-analysis to evaluate the risk and benefits of triple antithrombotic therapy versus dual antithrombotic therapy in patients undergoing coronary stent implantation, requiring long-term oral anticoagulation.

METHODS

We performed formal searches of PubMed, EMBASE, Cochrane central register of controlled trials and major international scientific session abstracts from January 1990 to September 2015 regarding the use of triple antithrombotic therapy (TT) versus dual therapy (DT) in patients undergoing percutaneous coronary stent implantation that required chronic oral anticoagulation. Data regarding study design, inclusion/exclusion criteria, number of patients, and selected endpoints was extracted by 2 investigators. Disagreements were resolved by consensus.

RESULTS

Sixteen trials with a total of 21716 patients undergoing coronary stent implantation with indication to long term oral anticoagulation, were finally included. A total of 6950 received TT, whereas 14766 received DT alone. The follow-up period ranged from 180 to 730 days. Data regarding mortality were available in 21658 patients (99.7 %). All cause mortality was observed in 10.4 % patients in TT versus 16.3 % in DT (OR [95 % CI] =0.73 [0.66-0.80], p <0.001; p _het <0.001). In addition, TT was associated with a reduced incidence of MI (6.4 versus 9.8 %, OR [95 % CI] = 0.74 [0.65-0.84], p < 0.001; p_het < 0.001) and ischemic stroke (1.8 versus 3.9 %, OR [95 % CI] = 0.55 [0.45-0.68], p < 0.001; p _het  = 0.07). As expected, TT was associated with a significant increase in major bleeding events (10.8 versus 8.5 %, OR [95 % CI] = 1.38 [1.25-1.53], p < 0.001; p _het  = 0.02). By meta regression analysis we found that benefits in mortality with TT were inversely related with the risk of bleedings (beta [95 % CI] = 2.25 (1.55; 2.95), p < 0.00001). The benefits with TT regarding overall mortality, recurrent MI and ischemic stroke were also confirmed in a pre-specified analysis versus DAPT or oral anticoagulation in association with a single antiplatelet agent.

CONCLUSION

This meta-analysis showed that among patients undergoing coronary stent implantation, requiring chronic OAC, the use of a TT is associated with a significant reduction in overall mortality, recurrent MI and ischemic stroke. As expected, we found a higher incidence of bleedings in patients treated with triple therapy. The benefits in mortality were lost in patients at high-risk for bleedings.

Triple Therapy Versus Dual Antiplatelet Therapy for Patients with Atrial Fibrillation and Acute Coronary Syndromes: A Systematic Literature Review

BACKGROUND

Patients with acute coronary syndromes (ACS) and a history of atrial fibrillation (AF) have indications for both dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC). Triple therapy (TT), the combination of DAPT and OAC, is recommended in guidelines. We examined studies comparing clinical outcomes on DAPT versus TT for patients with AF and ACS.

METHODS

We searched Medline, Medline pending, EMBASE and Evidence-Based Medicine Reviews databases for studies published between January 2000 to December 2016 in AF patients with ACS that compared DAPT and TT that reported ischaemic and/or bleeding outcomes. Studies that were not purely an AF population were excluded.

RESULTS

Ten studies were included in the review, all of which were observational, 8 of which were retrospective. None of the studies detailed the specifics of treatment allocation. All but one were of AF patients with a mix of stable coronary disease and ACS patients. TT was associated with increased bleeding when compared to DAPT, with adjusted odds ratios ranging from 1.25 to 6.84. While the largest study reported a reduction in stroke associated with TT (odds ratio 0.67), two other studies reported non-significant increases in stroke with TT. Variable composite ischaemic endpoints were reported, none showing a statistical significant difference between DAPT and TT.

CONCLUSION

In patients with ACS and AF, TT is likely to be associated with increased risk of bleeding, without a clear reduction in ischaemic endpoints. The quality of the evidence to support current guidelines for this patient group was generally poor.

Strategies to Optimize Dual Antiplatelet Therapy After Coronary Artery Stenting in Acute Coronary Syndrome

The use of aspirin and a P2Y12 receptor antagonist as dual antiplatelet therapy (DAPT) has become the treatment of choice in patients with acute coronary syndrome (ACS) and percutaneous coronary intervention to prevent recurrent thrombotic events. Although DAPT is beneficial for most patients, few patients still experience recurrent thrombotic events and increased bleeding episodes. This article reviews current literature to identify various approaches that may enhance the DAPT benefit-risk ratio in patients with ACS. Three strategies addressed in this article include the following—(1) use of more potent antiplatelet agents other than clopidogrel; (2) addition of direct oral anticoagulants (DOACs) to DAPT; and (3) optimizing DAPT duration. Although the use of prasugrel or ticagrelor improves treatment efficacy, their use has been associated with increased risk of bleeding compared to clopidogrel. The combination of DOACs and DAPT may not be the most viable strategy because of its limited cardiovascular benefits and increased bleeding risks. The optimal duration of DAPT duration remains controversial. Most guidelines recommend 6 to 12 months of DAPT, whereas emerging studies have shown benefit for both shorter and longer duration of treatment. Risk stratification tools such as the DAPT score may play a role in individualizing DAPT duration according to patient’s ischemic and bleeding risks.

Comparing the clinical outcomes in patients with atrial fibrillation receiving dual antiplatelet therapy and patients receiving an addition of an anticoagulant after coronary stent implantation: A systematic review and meta-analysis of observational studies

BACKGROUND

Data regarding the clinical outcomes in patients with atrial fibrillation (AF) receiving dual antiplatelet therapy (DAPT) and an anticoagulant in addition to DAPT (DAPT + vitamin K antagonist [VKA]) after coronary stent implantation are still controversial. Therefore, in order to solve this issue, we aim to compare the adverse clinical outcomes in AF patients receiving DAPT and DAPT + VKA after percutaneous coronary intervention and stenting (PCI-S).

METHODS

Observational studies comparing the adverse clinical outcomes such as major bleeding, major adverse cardiovascular events, stroke, myocardial infarction, all-cause mortality, and stent thrombosis (ST) in AF patients receiving DAPT + VKA therapy, and DAPT after PCI-S have been searched from Medline, EMBASE, and PubMed databases. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on discontinuous variables, and the pooled analyses were performed with RevMan 5.3.

RESULTS

Eighteen studies consisting of a total of 20,456 patients with AF (7203 patients received DAPT + VKA and 13,253 patients received DAPT after PCI-S) were included in this meta-analysis. At a mean follow-up period of 15 months, the risk of major bleeding was significantly higher in DAPT + VKA group, with OR 0.62 (95% CI 0.50-0.77, P < 0.0001). There was no significant differences in myocardial infarction and major adverse cardiovascular event between DAPT + VKA and DAPT, with OR 1.27 (95% CI 0.92-1.77, P = 0.15) and OR 1.17 (95% CI 0.99-1.39, P = 0.07), respectively. However, the ST, stroke, and all-cause mortality were significantly lower in the DAPT + VKA group, with OR 1.98 (95% CI 1.03-3.81, P = 0.04), 1.59 (95% CI 1.08-2.34, P = 0.02), and 1.41 (95% CI 1.03-1.94, P = 0.03), respectively.

CONCLUSION

At a mean follow-up period of 15 months, DAPT + VKA was associated with significantly lower risk of stroke, ST, and all-cause mortality in AF patients after PCI-S compared with DAPT group. However, the risk of major bleeding was significantly higher in the DAPT + VKA group.

Antiplatelet and Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Coronary Stenting

Stroke prevention is the main priority in the management cascade of atrial fibrillation. Most patients require long-term oral anticoagulation (OAC) and may require percutaneous coronary intervention. Prevention of recurrent cardiac ischemia and stent thrombosis necessitate dual antiplatelet therapy (DAPT) for up to 12 months. Triple antithrombotic therapy with OAC plus DAPT of shortest feasible duration is warranted, followed by dual antithrombotic therapy of OAC and antiplatelet agent, and OAC alone after 12 months. Because of elevated risk of hemorrhagic complications, new-generation drug-eluting stents, lower-intensity OAC, radial access, and routine use of gastric protection with proton pump inhibitors are recommended.

Design and Rationale of the RE-DUAL PCI Trial: A Prospective, Randomized, Phase 3b Study Comparing the Safety and Efficacy of Dual Antithrombotic Therapy With Dabigatran Etexilate Versus Warfarin Triple Therapy in Patients With Nonvalvular Atrial Fibrillation Who Have Undergone Percutaneous Coronary Intervention With Stenting

Antithrombotic management of patients with atrial fibrillation (AF) undergoing coronary stenting is complicated by the need for anticoagulant therapy for stroke prevention and dual antiplatelet therapy for prevention of stent thrombosis and coronary events. Triple antithrombotic therapy, typically comprising warfarin, aspirin, and clopidogrel, is associated with a high risk of bleeding. A modest-sized trial of oral anticoagulation with warfarin and clopidogrel without aspirin showed improvements in both bleeding and thrombotic events compared with triple therapy, but large trials are lacking. The RE-DUAL PCI trial (NCT 02164864) is a phase 3b, a strategy of prospective, randomized, open-label, blinded-endpoint trial. The main objective is to evaluate dual antithrombotic therapy with dabigatran etexilate (110 or 150 mg twice daily) and a P2Y12 inhibtor (either clopidogrel or ticagrelor) compared with triple antithrombotic therapy with warfarin, a P2Y12 inhibtor (either clopidogrel or ticagrelor, and low-dose aspirin (for 1 or 3 months, depending on stent type) in nonvalvular AF patients who have undergone percutaneous coronary intervention with stenting. The primary endpoint is time to first International Society of Thrombosis and Hemostasis major bleeding event or clinically relevant nonmajor bleeding event. Secondary endpoints are the composite of all cause death or thrombotic events (myocardial infarction, or stroke/systemic embolism) and unplanned revascularization; death or thrombotic events; individual outcome events; death, myocardial infarction, or stroke; and unplanned revascularization. A hierarchical procedure for multiple testing will be used. The plan is to randomize ∼ 2500 patients at approximately 550 centers worldwide to try to identify new treatment strategies for this patient population.

Oral Anticoagulants With Dual Antiplatelet Therapy Versus Clopidogrel in Patients After Percutaneous Coronary Intervention: A Meta-Analysis

BACKGROUND

In patients on oral anticoagulation (OAC), dual antiplatelet therapy (DAPT) is often indicated after percutaneous coronary intervention (PCI).

AREAS OF UNCERTAINTY

We sought to investigate the effects of triple antithrombotic therapy (TT) versus dual therapy (DT) with OAC and clopidogrel on all-cause mortality, cardiovascular death, major bleeding, myocardial infarction (MI), stroke, and stent thrombosis.

DATA SOURCES

We systematically searched on MEDLINE, EMBASE, and CENTRAL for randomized controlled or cohort studies, which investigated the comparative effects of TT versus DT. We performed a meta-analysis of 6 studies (1 randomized control study and 5 cohort studies).

RESULTS

The included studies enrolled 7259 patients; 4630 (63.8%) were on TT and 2629 (36.2%) were on DT. The average follow-up time was 1.4 years. No significant differences were found between TT and DT in all-cause mortality (P = 0.70; I = 64%), stent thrombosis (P = 0.41), myocardial infarction (P = 0.43; I = 0%), stroke (P = 0.36; I = 0%), and major bleeding (P = 0.43; I = 0%).

CONCLUSIONS

In patients who are on OAC with vitamin K antagonist and underwent percutaneous coronary intervention, no significant differences were found in mortality, ischemic, and hemorrhagic complications between the patients treated with TT and DT. Thus, tailored treatment based on individual thromboembolic and bleeding risk might be the most reasonable approach in these patients.

Triple antithrombotic therapy versus dual antiplatelet therapy in patients with atrial fibrillation undergoing drug-eluting stent implantation

BACKGROUND

The optimal antithrombotic regimen in patients with atrial fibrillation (AF) undergoing drug-eluting stent (DES) implantation for complex coronary artery disease is unclear. We compared the net clinical outcomes of triple antithrombotic therapy (TAT; aspirin, thienopyridine, and warfarin) and dual antiplatelet therapy (DAPT; aspirin and thienopyridine) in AF patients who had undergone DES implantation.

METHODS

A total of 367 patients were enrolled and analyzed retrospectively; 131 patients (35.7%) received TAT and 236 patients (64.3%) received DAPT. DAPT and warfarin were maintained for a minimum of 12 and 24 months, respectively. The primary endpoint was the 2-year net clinical outcomes, a composite of major bleeding and major adverse cardiac and cerebral events (MACCE). Propensity score-matching analysis was carried out in 99 patient pairs.

RESULTS

The 2-year net clinical outcomes of the TAT group were worse than those of the DAPT group (34.3 vs. 21.1%, P=0.006), which was mainly due to the higher incidence of major bleeding (16.7 vs. 4.6%, P<0.001), without any significant increase in MACCE (22.1 vs. 17.7%, P=0.313). In the multivariate analysis, TAT was an independent predictor of worse net clinical outcomes (odds ratio 1.63, 95% confidence interval 1.06-2.50) and major bleeding (odds ratio 3.54, 95% confidence interval 1.65-7.58). After propensity score matching, the TAT group still had worse net clinical outcomes and a higher incidence of major bleeding compared with the DAPT group.

CONCLUSION

In AF patients undergoing DES implantation, prolonged administration of TAT may be harmful due to the substantial increase in the risk for major bleeding without any reduction in MACCE.