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Mo R, Wang HY, Yang YM, Zhang H, Suo N, Wang JY. Implications of bleeding on subsequent cardiovascular events in patients with atrial fibrillation after acute coronary syndrome or PCI. Thromb Res 2023; 229:243-251. [PMID: 37591154 DOI: 10.1016/j.thromres.2023.08.002] [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: 01/15/2023] [Revised: 06/22/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
INTRODUCTION The association between bleeding and subsequent major adverse cardiac and cerebrovascular events (MACCE) remains poorly characterized. We aimed to evaluate the impact of hemorrhagic events in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). MATERIALS AND METHODS A total of 1877 consecutive patients with AF and ACS or undergoing PCI were prospectively recruited. The primary endpoint was MACCE, including all-cause death, myocardial infarction, ischemic stroke, systemic embolism or ischemia-driven revascularization during follow-up. Post-discharge bleeding was graded according to TIMI criteria. Associations between bleeding and subsequent MACCE were examined using time-dependent multivariate Cox regression after adjusting for baseline covariates and the time from bleeding. RESULTS During a median follow-up of 34.2 months, 341 (18.2 %) had TIMI major or minor bleeding events, of whom 86 (25.2 %) also experienced MACCE. The risk of MACCE was significantly higher in patients with bleeding than those without (8.85 % versus 6.99 % per patient-year; HR, 1.568, 95 % CI, 1.232-1.994). In patients who had both bleeding and MACCE, 65.1 % (56 of 86) bleeding events occurred first. Temporal gradients in MACCE risk after major bleeding was highest within 30 days (HRadj, 23.877; 95 % CI, 12.810-44.506) and remained significant beyond 1 year (HRadj, 3.640; 95 % CI, 1.278-10.366). Minor bleeding was associated with increased risk of MACCE within 1 year. CONCLUSIONS In patients with AF and ACS or PCI, major and minor bleeding were associated with subsequent MACCE with time-dependency. Our findings may aid in better defining net clinical benefit of optimal antithrombotic therapy.
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Affiliation(s)
- Ran Mo
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.; National Center for Neurological Disorders, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Hao-Yu Wang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China.; State Key Laboratory of Cardiovascular Disease, No.167 North Lishi Road, Xicheng District, Beijing, China.; National Clinical Research Center of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Yan-Min Yang
- State Key Laboratory of Cardiovascular Disease, No.167 North Lishi Road, Xicheng District, Beijing, China.; National Clinical Research Center of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China.; Emergency Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China..
| | - Han Zhang
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Ni Suo
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Jing-Yang Wang
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China
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Patti G, Haas S. Non-Vitamin K Antagonist Oral Anticoagulants and Factors Influencing the Ischemic and Bleeding Risk in Elderly Patients With Atrial Fibrillation: A Review of Current Evidence. J Cardiovasc Pharmacol 2020; 77:11-21. [PMID: 33060545 PMCID: PMC7774815 DOI: 10.1097/fjc.0000000000000927] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/04/2020] [Indexed: 10/31/2022]
Abstract
ABSTRACT Non-vitamin K antagonist oral anticoagulants (NOACs) are a widely prescribed treatment to prevent stroke in patients with nonvalvular atrial fibrillation, and a therapy and preventative measure to prevent recurrences following venous thromboembolism. Optimal use of NOACs requires a thorough knowledge of the pharmacology of these drugs, as well as an understanding of patient factors affecting their use. The 4 NOACs-dabigatran, apixaban, edoxaban, and rivaroxaban are available in a range of doses suitable for differing indications and with a variety of dose reduction criteria. Identification of the correct dose is one of the key challenges in the individualization of treatment. Elderly patients with atrial fibrillation are at a greater risk of both ischemic and bleeding events than younger patients. Consequently, it is essential to achieve balance in anticoagulation strategies. Medication adherence to NOACs is important for safe and effective treatment, particularly in elderly populations. A growing body of evidence shows that once-daily dosing improves adherence and persistence to therapy, without having an impact on bleeding risk.
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Affiliation(s)
- Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy; and
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
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3
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Santoso A, Raharjo SB. Combination of Oral Anticoagulants and Single Antiplatelets versus Triple Therapy in Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome: Stroke Prevention among Asians. Int J Angiol 2020; 29:88-97. [PMID: 32499669 DOI: 10.1055/s-0040-1708477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Atrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)-vascular disease, age 65 to 74 years, sex category (female; CHA 2 DS 2 -VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, "triple therapy" comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for "triple therapy" would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.
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Affiliation(s)
- Anwar Santoso
- Department of Cardiology-Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
| | - Sunu B Raharjo
- Department of Cardiology-Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.,National Cardiovascular Centre, Harapan Kita Hospital, Jakarta, Indonesia
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Drug-eluting versus bare-metal stents for first myocardial infarction in patients with atrial fibrillation: A nationwide population-based cohort study. PLoS One 2020; 15:e0227571. [PMID: 31923246 PMCID: PMC6953848 DOI: 10.1371/journal.pone.0227571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/21/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) complicates the clinical management of atrial fibrillation (AF) because coronary stenting may influence subsequent antithrombotic therapy. We investigated the use of a bare-metal stent (BMS) or a drug-eluting stent (DES) and associated outcomes in patients with pre-existing AF and first AMI undergoing percutaneous coronary intervention. METHODS AND RESULTS Patient records in this population-based study were retrospectively collected from the Taiwan National Health Insurance Research Database. Using propensity score matching (PSM), we used 1:2 ratio stratification into a DES group of 436 and a BMS group of 785 patients from 2007 to 2011. The mean follow-up of matched cohorts was 1.7 years. After PSM, DESs were associated with lower rates of cardiovascular death (7.8%, hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.86 and 10.1%, HR 0.64, 95% CI 0.45-0.90) and primary composite outcome (35.1%, HR 0.76, 95% CI 0.63-0.92 and 48.2%, HR 0.81, 95% CI 0.69-0.96) than BMSs within the first year and at the end of follow-up. Although the greatest benefit from DESs, irrespective of the first- and second- generation DESs, implantation was observed within the first year only, this benefit was not observed in patients with diabetes, chronic kidney disease, or dialysis. CONCLUSIONS Use of DESs in AMI patients with pre-existing AF is associated with significantly lower rates of cardiovascular death and primary composite outcome within the first year follow-up. However, the effect is not apparent in patients with diabetes, chronic kidney disease or dialysis.
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Curtis AB, Karki R, Hattoum A, Sharma UC. Arrhythmias in Patients ≥80 Years of Age: Pathophysiology, Management, and Outcomes. J Am Coll Cardiol 2019; 71:2041-2057. [PMID: 29724357 DOI: 10.1016/j.jacc.2018.03.019] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/12/2018] [Accepted: 03/12/2018] [Indexed: 12/14/2022]
Abstract
Advances in medical care have led to an increase in the number of octogenarians and even older patients, forming an important and unique patient subgroup. It is clear that advancing age is an independent risk factor for the development of most arrhythmias, causing substantial morbidity and mortality. Patients ≥80 years of age have significant structural and electrical remodeling of cardiac tissue; accrue competing comorbidities; react differently to drug therapy; and may experience falls, frailty, and cognitive impairment, presenting significant therapeutic challenges. Unfortunately, very old patients are under-represented in clinical trials, leading to critical gaps in evidence to guide effective and safe treatment of arrhythmias. In this state-of-the-art review, we examine the pathophysiology of aging and arrhythmias and then present the available evidence on age-specific management of the most common arrhythmias, including drugs, catheter ablation, and cardiac implantable electronic devices.
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Affiliation(s)
- Anne B Curtis
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York.
| | - Roshan Karki
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Alexander Hattoum
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Umesh C Sharma
- Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York
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Sambola A, Bueno H, Miranda B, Hernandez AV, Limeres J, Del Blanco BG, García-Dorado D. Safe and Efficacious Use of 1-Month Triple Therapy in Patients with Atrial Fibrillation and High Bleeding Risk Undergoing PCI. Cardiovasc Drugs Ther 2019; 33:425-433. [PMID: 31332653 DOI: 10.1007/s10557-019-06889-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The impact of short or prolonged use of triple therapy (TT) on outcomes in patients with atrial fibrillation (AF) and high risk of bleeding undergoing percutaneous coronary intervention (PCI) is unclear. We compared clinical outcomes according to the duration of TT in patients with AF and HAS-BLED ≥ 3 at 1 year of follow-up. METHODS A prospective observational cohort enrolled 735 patients with AF between 2010 and 2015. Of these, 521 (70.9%) had HAS-BLED ≥ 3 and 380 (72.9%) were discharged on TT. TT was prescribed for 1 month in 233 patients (61.3%). The primary endpoint was the incidence of Bleeding Academic Research Consortium (BARC ≥ 3). The secondary endpoint was the occurrence of ischemic events (cardiac death, MI, stroke, or stent thrombosis). RESULTS Patients on 1-month TT had a higher median HAS-BLED. Intracraneal hemorrhage was twofold more frequently in patients on > 1-month TT but without statistical significance (0.9% vs 2.1%, p = 0.20). Rates of the primary endpoint (bleeding BARC ≥ 3) were 8.2% vs 10.9% and did not differ between groups, while secondary endpoint did not occur more frequently in the 1-month TT group compared with the > 1-month TT group (26.6% vs 23.1%). In adjusted multivariate analyses, patients receiving 1-month TT had a similar risk of the primary endpoint compared to those with > 1-month TT (HR 1.47; 95% CI 0.48-4.47, p = 0.50). No difference was found in the secondary ischemic endpoint (HR 1.24; 95% CI 0.77-2.00, p = 0.38). CONCLUSIONS In patients with AF undergoing PCI at lower ischemic risk and higher bleeding risk, 1 month of TT seems safe and efficacious. Further studies are warranted in patients at high ischemic risk.
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Affiliation(s)
- Antonia Sambola
- Department of Cardiology, Hospital Vall d'Hebron University, Barcelona, Spain. .,Research Institute Vall d'Hebron, Universitat Autònoma de Barcelona, 119-129, 08035, Barcelona, Spain.
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) Cardiovascular Research Area, Research Institute CCU, Department of Cardiology, Hospital 12 de Octubre University, Madrid, Spain
| | - Berta Miranda
- Department of Cardiology, Hospital Vall d'Hebron University, Barcelona, Spain.,Research Institute Vall d'Hebron, Universitat Autònoma de Barcelona, 119-129, 08035, Barcelona, Spain
| | - Adrian V Hernandez
- University of Connecticut/Hartford Hospital Evidence-based Practice Center, Hartford, CT, 06102, USA.,Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru
| | - Javier Limeres
- Department of Cardiology, Hospital Vall d'Hebron University, Barcelona, Spain.,Research Institute Vall d'Hebron, Universitat Autònoma de Barcelona, 119-129, 08035, Barcelona, Spain
| | - Bruno García Del Blanco
- Department of Cardiology, Hospital Vall d'Hebron University, Barcelona, Spain.,Research Institute Vall d'Hebron, Universitat Autònoma de Barcelona, 119-129, 08035, Barcelona, Spain
| | - David García-Dorado
- Department of Cardiology, Hospital Vall d'Hebron University, Barcelona, Spain.,Research Institute Vall d'Hebron, Universitat Autònoma de Barcelona, 119-129, 08035, Barcelona, Spain
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7
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Limeres J, Lip GY, del Blanco BG, Ferreira-González I, Mutuberria M, Alfonso F, Bueno H, Cequier A, Prendergast B, Zueco J, Rodríguez-Leor O, Barrabés JA, García-Dorado D, Sambola A. Safety of drug-eluting stents compared to bare metal stents in patients with an indication for long-term oral anticoagulation: A propensity score matched analysis. Thromb Res 2019; 177:180-186. [DOI: 10.1016/j.thromres.2019.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/09/2019] [Accepted: 02/18/2019] [Indexed: 01/10/2023]
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8
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Bleeding risk assessment in elderly patients with acute coronary syndrome. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2019; 16:145-150. [PMID: 30923546 PMCID: PMC6431601 DOI: 10.11909/j.issn.1671-5411.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nowadays, elderly people represent a growing population segment with a well known increased risk of both ischemic and bleeding events. Current acute coronary syndrome guidelines, strongly recommend dual antiplatelet therapy (DAPT) with few specific references for aged patients due to lack of evidence. Patients aged ≥ 75 years are misrepresented in the classic derivation trials cohorts. Strategies to reduce the bleeding risk in this group of patients are urgently needed for the daily clinical practice. Identify the specific age related bleeding risk factors and the importance of an integral geriatric assessment remains challenging. Some of the available in-hospital and out-hospital bleeding risk scores have shown a lower to moderate predictive ability in older patients and no specific tools are developed in elderly population. The importance of an appropriate vascular access choice, type and duration of antiplatelet drugs is crucial to reduce the bleeding risk. Increase radial approaches and short DAPT duration leads to reduce hemorrhages. One interesting subgroup of patients is those who need chronic anticoagulation therapy after percutaneous coronary intervention, due to their very high risk of bleeding. New alternatives as dual therapy with oral anticoagulation and only one antiplatlet drug should be considered. In current review, we evaluate the available evidence about bleeding risk in elderly.
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9
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Gallet R, Teiger E. [Oral anticoagulants in elderly patients with coronary artery disease and atrial fibrillation]. Ann Cardiol Angeiol (Paris) 2018; 67:404-410. [PMID: 30342831 DOI: 10.1016/j.ancard.2018.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Anti-thrombotic management of percutaneous coronary intervention and atrial fibrillation relies on dual antiplatelet therapy and anticoagulation respectively. Because of people ageing, the coexistence of coronary artery disease and atrial fibrillation is increasing. This coexistence raises concerns about the anti-thrombotic strategy, particularly about the association of dual antiplatelet therapy and anticoagulation, known as triple therapy. This triple therapy is responsible for a dramatic increase in bleeding risk (3-4 fold) especially in elderlies. However, older patients are also at increased risk of ischemic events. In this setting, dual anti-thrombotic strategies combining non-vitamin K oral anticoagulants and a P2Y12 inhibitor have been developed. These strategies provide a net benefit by reducing bleeding events. Therefore, they are becoming an attractive alternative, especially for frailer patient. This article reviews the rational, risks and strategies of anti-thrombotic therapy in elderly people with coronary artery disease and atrial fibrillation.
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Affiliation(s)
- R Gallet
- Unité de cardiologie interventionnelle, CHU de Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - E Teiger
- Unité de cardiologie interventionnelle, CHU de Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
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10
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Ather A, Laliberte B, Reed BN, Schenk A, Watson K, Devabhakthuni S, See VY. Antithromboembolic Strategies for Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Am J Cardiovasc Drugs 2018; 18:441-455. [PMID: 29915905 DOI: 10.1007/s40256-018-0287-y] [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] [Indexed: 11/30/2022]
Abstract
We set out to synthesize available data on antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), with a focus on triple antithrombotic therapy (triple therapy [TT]; dual antiplatelet therapy plus an anticoagulant) versus dual therapy (DT; one antiplatelet agent and an anticoagulant). We searched OVID MEDLINE and PubMed from January 2005 to September 2017 using the search terms oral anticoagulant, triple therapy, dual therapy, acute coronary syndrome, percutaneous coronary intervention, and atrial fibrillation (limited to randomized controlled trials, observational studies, English language, minimum 6-12 months of follow-up, minimum 100 human patients). We excluded surveys, literature reviews, articles not directly related to TT versus DT, incomplete studies, and short-term in-hospital studies. All eligible studies were reviewed to evaluate possible antithrombotic management strategies for patients with AF undergoing PCI. Extracted studies were categorized according to the specific anticoagulant (vitamin K antagonist vs. direct-acting oral anticoagulant) and P2Y12 inhibitor used. Each category review was followed by a discussion providing insight into the quality of evidence and implications for practice. We found that the risk of bleeding with TT was higher than with DT, without demonstrated added benefit of reducing major adverse cardiovascular events. TT use should be minimized in patients with high bleeding risk, and patient-specific factors should be critically analyzed to select appropriate antiplatelet and anticoagulant agents.
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Affiliation(s)
- Ayesha Ather
- Department of Pharmacy Services, UK HealthCare, University of Kentucky College of Pharmacy, 800 Rose Street, H110, Lexington, KY, 40536, USA.
| | - Benjamin Laliberte
- Department of Pharmacy, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Brent N Reed
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, ATRIUM Cardiology Collaborative, 20 N Pine Street, Office S428, Baltimore, MD, 21201, USA
| | - Ashley Schenk
- Department of Pharmacy Services, UK HealthCare, University of Kentucky College of Pharmacy, 800 Rose Street, H110, Lexington, KY, 40536, USA
| | - Kristin Watson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, ATRIUM Cardiology Collaborative, 20 N Pine Street, Office S447, Baltimore, MD, 21201, USA
| | - Sandeep Devabhakthuni
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, ATRIUM Cardiology Collaborative, 20 N Pine Street, Pharmacy Hall Rm S430, Baltimore, MD, 21201, USA
| | - Vincent Y See
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD, 21201, USA
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11
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Long-term outcomes in surgically ineligible patients managed with percutaneous coronary revascularization or medical therapy. Cardiovasc Interv Ther 2018; 34:249-259. [DOI: 10.1007/s12928-018-0554-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022]
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12
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Esmonde S, Sharma D, Peace A. Antiplatelet agents in uncertain clinical scenarios-a bleeding nightmare. Cardiovasc Diagn Ther 2018; 8:647-662. [PMID: 30498688 PMCID: PMC6232352 DOI: 10.21037/cdt.2018.06.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/28/2018] [Indexed: 12/14/2022]
Abstract
Despite over 40 years since the first percutaneous coronary intervention (PCI) was performed, the optimal dual antiplatelet therapy (DAPT) regime poses a significant challenge for clinicians, especially in certain scenarios. DAPT is the standard of care in PCI following an acute coronary syndrome (ACS) or for elective patients with obstructive coronary artery disease (CAD). There remains significant uncertainty regarding DAPT in patients at high risk of bleeding, such as the elderly and patients requiring anticoagulation. More and more clinicians are faced with a dilemma of weighing risks and benefits from the increasing list of potent, new antiplatelet agents and direct oral anticoagulants (DOACs) in a growing, aging population. Historically, most studies failed to recognize bleeding risk, instead focusing on ischemic risk. In recent years however, bleeding has been recognized as a very significant driver of morbidity and mortality in patients undergoing PCI. There is a paucity of data in this cohort leading to divergent and sometimes conflicting recommendations, largely based on expert consensus of opinion. In the current review, we critically evaluate the available evidence in these uncertain scenarios.
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Affiliation(s)
- Sean Esmonde
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
| | - Divyesh Sharma
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
| | - Aaron Peace
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
- Northern Ireland Centre for Stratified Medicine, Ulster University, C-TRIC, Derry/Londonderry, Northern Ireland, UK
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13
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Lip GYH, Collet JP, Haude M, Byrne R, Chung EH, Fauchier L, Halvorsen S, Lau D, Lopez-Cabanillas N, Lettino M, Marin F, Obel I, Rubboli A, Storey RF, Valgimigli M, Huber K, Potpara T, Blomström Lundqvist C, Crijns H, Steffel J, Heidbüchel H, Stankovic G, Airaksinen J, Ten Berg JM, Capodanno D, James S, Bueno H, Morais J, Sibbing D, Rocca B, Hsieh MH, Akoum N, Lockwood DJ, Gomez Flores JR, Jardine R. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2018; 21:192-193. [DOI: 10.1093/europace/euy174] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Jean-Phillippe Collet
- Sorbonne Université Paris 6, ACTION Study Group (www.action-coeur.org), Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), INSERM UMRS, Paris, France
| | - Michael Haude
- Städtische Kliniken Neuss Lukaskrankenhaus Gmbh Kardiologie, Nephrologie, Pneumologie, Neuss, Germany
| | - Robert Byrne
- Deutsches Herzzentrum Muenchen, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Eugene H Chung
- University of North Carolina at Chapel Hill, Medicine, Cardiology, Electrophysiology, Chapel Hill, NC, USA
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Faculté de Médecine—Université François Rabelais, Tours, France
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dennis Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Maddalena Lettino
- Cardiology Department, Humanitas Research Hospital, Rozzano, MI, Italy
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Israel Obel
- Milpark Hospital, Cardiology Unit, Johannesburg, South Africa
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital Vienna, Vienna, Austria
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Harry Crijns
- Cardiology Department, Maastricht UMC+, Maastricht, Netherlands
| | - Jan Steffel
- University Heart Center Zurich, Zurich, Switzerland
| | - Hein Heidbüchel
- Antwerp University and University Hospital, Antwerp, Belgium
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Juhani Airaksinen
- Turku University Hospital, Cardiology, Department of Internal Medicine, Turku, Finland
| | | | - Davide Capodanno
- Ferrarotto Hospital, Azienda Ospedaliero-Univ, Policlinico-Vittorio Emanuele, University of Catania, Cardiologia Department, University of Catania, Catania, Italy
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Senior Interventional Cardiologist, Uppsala University Hospital, Uppsala, Sweden
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernandez Almagro, Madrid, Spain
- Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Joao Morais
- Department of Cardiology, Leiria Hospital Centre, Portugal
| | - Dirk Sibbing
- Oberarzt, Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-Universität (LMU), Campus Großhadern, München, Germany
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | | | - Nazem Akoum
- Cardiology Department, University of Washington, Seattle, USA
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Optimal antithrombotic treatment in patients with atrial fibrillation and coronary stents: an update. Curr Opin Cardiol 2018; 31:356-65. [PMID: 27205887 DOI: 10.1097/hco.0000000000000306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The optimal antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI) is still debated. This review is an update of a previous review and aims to summarize new published data regarding the management of this group of atrial fibrillation patients. RECENT FINDINGS Recent data report an underuse of oral anticoagulation in patients with atrial fibrillation undergoing PCI while indicated. However, tools for risk assessment and thus better guidance for decision-making are lacking, especially for elderly atrial fibrillation patients. New evidence suggests that the combination of oral anticoagulation and clopidogrel without aspirin may improve clinical outcomes in comparison with triple therapy; however, there is little data regarding the role of non-vitamin K oral anticoagulants and newer P2Y12 inhibitors in these regimens. SUMMARY Despite accumulating data on the assessment of bleeding and thrombotic risk, the management of elderly atrial fibrillation patients, new treatment regimens, and the role of more potent antithrombotic agents, the optimal antithrombotic therapy for patients with atrial fibrillation after PCI is still unclear. In the meantime, careful assessment of both thrombotic and bleeding risk and individualized decision-making are paramount to ensure the best patient outcomes.
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Serebruany V, Lomakin N, Marciniak T. Meta-analyses of incomplete trial datasets: unreliable and potentially misleading. Heart 2018; 104:630-631. [PMID: 28988208 DOI: 10.1136/heartjnl-2017-312292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Victor Serebruany
- Division of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nikita Lomakin
- Department of Intensive Cardiology, Central Clinical Hospital of the Administrative Affairs of the President of the Russian Federation, Moscow, Russian
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D'Angelo RG, McGiness T, Waite LH. Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: Where Are We Now? Ann Pharmacother 2018; 52:884-897. [PMID: 29577768 DOI: 10.1177/1060028018766837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
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.
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Affiliation(s)
- Ryan G D'Angelo
- 1 University of the Sciences-Philadelphia College of Pharmacy, Philadelphia, PA, USA.,2 Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Thaddeus McGiness
- 1 University of the Sciences-Philadelphia College of Pharmacy, Philadelphia, PA, USA.,2 Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Laura H Waite
- 1 University of the Sciences-Philadelphia College of Pharmacy, Philadelphia, PA, USA.,2 Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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17
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Antithrombotic therapy strategies for atrial fibrillation patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis. PLoS One 2017; 12:e0186449. [PMID: 29023526 PMCID: PMC5638551 DOI: 10.1371/journal.pone.0186449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/15/2017] [Indexed: 11/30/2022] Open
Abstract
Objective The aim of this systematic review and network meta-analysis was to evaluate the comparative efficacy and safety of antiplatelet agents, vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). Methods PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify clinical trials comparing antiplatelet drugs with VKA and NOACs or their combination in AF patients undergoing PCI with a mean/median follow-up of at least 12 months. A network meta-analysis was conducted to directly and indirectly compare the efficacy and safety of competitive antithrombotic regimens with a Bayesian random-effects model. Results were presented as relative risks (RRs) and 95% confidence intervals (CIs). Results A total of 15 studies enrolling 13,104 patients were included. Among 5 regimens, rivaroxaban 15 mg daily plus P2Y12 inhibitor treatment demonstrated significant superiority over dual- and triple-antiplatelet therapies (DAPT, TT) in reducing thromboembolic events (0.64 [0.38, 0.95] and 0.68 [0.43, 0.98], respectively) but showed the maximum possibility of major bleeding risk, while VKA plus single antiplatelet therapy (SAPT) seemed the safest. Significantly less risk of major bleeding was seen in DAPT group than that in TT group (0.63 [0.39, 0.99]). Conclusions The present study suggests that combination of VKA and SAPT is the best choice for AF patients undergoing PCI considering both efficacy and safety. Rivaroxaban 2.5 mg twice daily plus DAPT treatment owns the highest probability to be the optimal alternative to VKA plus SAPT for these patients.
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18
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Zhu W, Guo L, Liu F, Wan R, Shen Y, Lip GY, Hong K. Efficacy and safety of triple versus dual antithrombotic therapy in atrial fibrillation and ischemic heart disease: a systematic review and meta-analysis. Oncotarget 2017; 8:81154-81166. [PMID: 29113375 PMCID: PMC5655270 DOI: 10.18632/oncotarget.20870] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/26/2017] [Indexed: 12/18/2022] Open
Abstract
The optimal antithrombotic regimen for patients with atrial fibrillation and ischemic heart disease remains unclear. Therefore, we aimed to compare the efficacy and safety of triple therapy (TT [an anticoagulant and 2 antiplatelet drugs]) with dual therapy (DAPT [2 antiplatelet drugs] or DT [an anticoagulant and a single antiplatelet drug]) in patients with atrial fibrillation and ischemic heart disease. We systematically searched the Cochrane Library, PubMed and Embase databases for all relevant studies up to August 2017. The overall risk estimates were calculated using the random-effects model. A total of 17 observational studies were included. Regarding the efficacy outcomes, no differences were observed between the triple therapy and the dual therapy for all-cause death, cardiovascular death, or thrombotic complications (i.e., acute coronary syndrome, stent thrombosis, thromboembolism/stroke, and major adverse cardiac and cerebrovascular events). Regarding the safety outcomes, compared with DAPT, TT was associated with increased risks of major bleeding (a relative risk of 1.96 [1.40-2.74]), minor bleeding (1.69 [1.06-2.71]) and overall bleeding (1.80 [1.23-2.64]). Compared wtih DT, TT was associated with a greater risk of major bleeding (1.65 [1.23-2.21]), but rates of minor bleeding (0.99 [0.56-1.77]) and overall bleeding (1.14 [0.76-1.71]) were similar. Overall, TT confers an increased hazard of major bleeding with no thromboembolic protection compared with dual therapy in patients with atrial fibrillation and ischemic heart disease.
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Affiliation(s)
- Wengen Zhu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang of Jiangxi, China
| | - Linjuan Guo
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang of Jiangxi, China
| | - Fadi Liu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang of Jiangxi, China
| | - Rong Wan
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang of Jiangxi, China
| | - Yang Shen
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang of Jiangxi, China
| | - Gregory Y.H. Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
| | - Kui Hong
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang of Jiangxi, China
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang of Jiangxi, China
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19
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Proietti M, Airaksinen KEJ, Rubboli A, Schlitt A, Kiviniemi T, Karjalainen PP, Lip GY. Time in therapeutic range and major adverse outcomes in atrial fibrillation patients undergoing percutaneous coronary intervention: The Atrial Fibrillation Undergoing Coronary Artery Stenting (AFCAS) registry. Am Heart J 2017; 190:86-93. [PMID: 28760217 DOI: 10.1016/j.ahj.2017.05.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/30/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Combination of oral anticoagulation (OAC) and antiplatelets is used in atrial fibrillation (AF) patients undergoing percutaneous coronary intervention and stent (PCI-S) procedure but is associated with increased bleeding when triple antithrombotic therapy (TAT) is used. Our aim was to analyze the impact of time in therapeutic range (TTR) on outcomes, in patients prescribed with TAT. METHODS Ancillary analysis from the AFCAS registry in patients assigned to TAT. TTR was calculated with Rosendaal method. Outcomes were analyzed according to TTR tertiles (T1 [≤56.8%] vs. T2 [56.9-93.8%] vs. T3 [≥93.9%]). Major bleeding was the primary outcome. RESULTS Of 963 patients enrolled, 470(48.8%) were prescribed with TAT at discharge and qualified for this analysis. Median [IQR] TTR was 80.0% [45.3-100%]. After 359 [341-370] days, major bleeding rates were progressively lower with increasing TTR tertiles (T1 vs. T2 vs. T3: 10.3% vs. 4.7% vs. 2.3%, P=.006). Kaplan-Meier analysis demonstrated a progressively lower risk for major bleeding across tertiles (P=.006). Patients in the highest TTR tertile had a non-significant lower risk for major adverse coronary and cerebrovascular events (MACCE) (log-rank: 4.905, P=.086). Cox regression analysis showed that T2 and T3 were inversely associated with major bleeding (hazard ratio [HR]:0.39, P=.050 and HR: 0.21, P=.005). Continuous TTR was inversely associated with major bleeding (HR: 0.98, P<.001). For MACCE, adjusted Cox analysis found a non-significant lower risk for T3 (HR: 0.64, P=.128). CONCLUSIONS In AF patients undergoing PCI-S prescribed TAT, good quality anticoagulation control (as reflected by TTR) was closely related to bleeding outcomes during follow-up. Despite some suggestive trends for an inverse relationship between TTR and MACCE, no definitive conclusions can be drawn, and further large studies are needed.
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Affiliation(s)
- Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy
| | - Axel Schlitt
- Department of Medicine III, Martin Luther-University, Halle, Germany
| | - Tuomas Kiviniemi
- Department of Cardiology, Paracelsus Harz-Clinic, Bad Suderode, Germany
| | | | - Gregory Yh Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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20
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Zhai HB, Liu J, Dong ZC, Wang DX, Zhang B. Current Use of Oral Anticoagulants and Prognostic Analysis in Patients with Atrial Fibrillation Undergoing Coronary Stenting. Chin Med J (Engl) 2017; 130:1418-1423. [PMID: 28584203 PMCID: PMC5463470 DOI: 10.4103/0366-6999.207460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: It is currently believed that triple oral antithrombotic therapy in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI) should be recommended if there are no contraindications. However, selecting triple therapy for AF patients undergoing PCI is still challenging when bleeding risk is considered. This study aimed to investigate the current use of oral anticoagulants (Vitamin K antagonists [VKA]) and perform prognostic analysis in real-world patients with AF undergoing coronary stenting. Methods: A total of 276 consecutive coronary artery disease (CAD) patients with or without AF undergoing coronary stenting were retrospectively evaluated and analyzed. The univariate and multivariate analyses were conducted to explore the current use of VKA and prognosis of patients with AF undergoing coronary stenting. The primary end-point was composite of all-cause death, nonfatal recurrent myocardial infarction, stroke, serious bleeding events, unplanned repeat revascularization, and worsening heart failure at 12-month follow-up after coronary stenting. Results: AF patients undergoing coronary stenting have more clinical concomitant diseases. Only 9.0% AF patients after coronary stenting received triple antithrombotic therapy (VKA, aspirin, and clopidogrel) at discharge. AF was independently associated with increased risk of the 12-month composite end-points (relative risk = 5.732, 95% confidence interval 1.786–18.396, P = 0.003). Conclusions: In real-life AF patients undergoing coronary stenting, guideline-recommended VKA was less used. AF patients had adjusted worse prognosis during 12-month follow-up after discharge. It is of utmost importance to improve the current status of oral anticoagulants use.
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Affiliation(s)
- Heng-Bo Zhai
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011; Department of Cardiology, The General Hospital of Shenyang Military, Shenyang, Liaoning 110016, China
| | - Jun Liu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Zhi-Chao Dong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Dong-Xia Wang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Bo Zhang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
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21
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Fake A, Ranchord A, Harding S, Larsen P. Triple Therapy Versus Dual Antiplatelet Therapy for Patients with Atrial Fibrillation and Acute Coronary Syndromes: A Systematic Literature Review. Curr Cardiol Rev 2017; 13:325-333. [PMID: 28969538 PMCID: PMC5730966 DOI: 10.2174/1573403x13666170927121808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/12/2017] [Accepted: 09/20/2017] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Aimee Fake
- Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand
- Wellington Cardiovascular Research Group, Wellington, New Zealand
| | - Anil Ranchord
- Wellington Cardiovascular Research Group, Wellington, New Zealand
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Scott Harding
- Wellington Cardiovascular Research Group, Wellington, New Zealand
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Peter Larsen
- Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand
- Wellington Cardiovascular Research Group, Wellington, New Zealand
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22
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Chaudhary N, Bundhun PK, Yan H. 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. Medicine (Baltimore) 2016; 95:e5581. [PMID: 27977592 PMCID: PMC5268038 DOI: 10.1097/md.0000000000005581] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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High platelet reactivity after P2Y12-inhibition in patients with atrial fibrillation and coronary stenting. J Thromb Thrombolysis 2016; 42:558-65. [PMID: 27387715 DOI: 10.1007/s11239-016-1397-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
High platelet reactivity (HPR) after P2Y12-inhibition in patients undergoing coronary stenting is associated with an increased risk for thromboembolic events and coronary death. So far it is not known how HPR affects the clinical outcome of different treatment strategies in patients with atrial fibrillation (AF) undergoing coronary stenting. In this single centre, observational study the antiplatelet effect of P2Y12-inhibitors in AF patients undergoing coronary stenting was investigated using impedance aggregometry. Patients received either dual antiplatelet therapy (DAPT) or triple therapy (TT). HPR was defined as the ratio of ADP-to TRAP-induced aggregation (r-ADP-agg) ≥50 %. Thromboembolic and bleeding events were assessed within the first 30 days after stenting. Out of 910 screened patients 167 patients were available for the present analysis. HPR was found in 5 of 43 (12 %) patients treated with DAPT and in 18 of 124 (15 %) patients treated with TT. In patients receiving TT, HPR was not a risk factor for thromboembolic events compared to patients with adequate response to P2Y12-inhibitors (6 vs. 8 %, p = 0.712). There was a trend for less bleeding events in patients with HPR compared to r-ADP-agg <50 % in the TT group (0 vs. 16 %, p = 0.077). Our data suggest that HPR after P2Y12-antagonism in patients receiving TT due to AF and coronary stenting might protect from bleeding without increasing thromboembolic risk. Future studies will need to investigate if patients with AF receiving coronary stenting benefit from a reduction of antithrombotic therapy.
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