Antithrombotic Management for Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention or With Acute Coronary Syndrome: An Evidence-Based Update

Trends in Off-Label Indications of Non-Vitamin K Antagonist Oral Anticoagulants in Acute Coronary Syndrome

Acute coronary syndrome (ACS) is a leading cause of mortality worldwide. Despite optimal antiplatelet therapy recommendation after ischemic events, recurrent thrombotic complications rate remains high. The recurrent events maybe in part due to increased thrombin levels during ACS which may underscore the need for an additional anticoagulation therapy. Given the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin, they have the potential to prevent thrombus formation, in the presence or absence of atrial fibrillation, but at the cost of increased risk of bleeding. NOACs have also shown a promising efficacy in managing left ventricular thrombus and a potential benefit in avoiding stent thrombosis after percutaneous coronary revascularization. Taken as a whole, NOACs are increasingly used for off-licence indications, and continue to evolve as essential therapy in preventing and treating thrombotic events. Herein, this review discusses NOACs off-label indications in the setting of ischemic coronary disease.

Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation

BACKGROUND

Since 2010, the European Society of Cardiology has extended prescription criteria for oral antithrombotic therapy (OAT) in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) were upgraded from an IIAa recommendation in 2012 to an IA in 2016. In real-world scenarios, however, OAC prescription is still suboptimal, mainly for DOACs.

AIM

To evaluate OAT temporal prescription patterns in a cohort of patients hospitalized with AF in a Cardiology Department.

METHODS

A retrospective observational study was conducted on a cohort of hospitalized patients in a secondary setting (Trapani, Italy) from 2010 to 2021 with AF as the main or secondary diagnosis. For 4089 consecutive patients, the variables extracted from the Cardiology department database were: Sex, age, time of hospitalization, antithrombotic therapy (warfarin, acenocoumarol, apixaban, dabigatran, edoxaban, rivaroxaban, aspirin, clopidogrel, other antiplatelet agents, low molecular weight heparin, and fondaparinux), diagnosis at discharge and used resources. Basal features are presented as percentage values for categorized variables and as mean +/- SD for categorized once.

RESULTS

From January 1st, 2010 to October 6th, 2021, 25132 patients were hospitalized in our department; 4089 (16.27%, mean age 75.59+/-10.82) were discharged with AF diagnosis; of them, 2245 were males (54.81%, mean age 73.56+/-11.45) and 1851 females (45.19%, mean age 78.06+/-9.47). Average length of stay was 5.76+/-4.88 days; 154 patients died and 88 were moved to other Departments/Structures. AF was the main diagnosis in 899 patients (21.94%). The most frequent main diagnosis in patients with AF was acute myocardial infarction (1973 discharges, 48.19%). The most frequent secondary cardiac diagnosis was chronic coronary syndrome (1864 discharges, 45.51%), and the most frequent secondary associated condition was arterial hypertension (1010 discharges, 24.66%). For the analysis of antithrombotic treatments, the final sample included 3067 patients, after excluding in-hospital deaths, transferred out or self-discharged patients, as well as discharges lacking indications for prescribed treatments. OAC treatment increased significantly (35.63% in 2010-2012 vs 61.18% in 2019-2021, +25.55%, P < 0.0001), in spite of any antiplatelet agent use. This rise was due to increasing use of DOACs, with or without antiplatelet agents, from 3.04% in 2013-2015 to 50.06% in 2019-2021 (+47.02%, P < 0.0001) and was greater for factor Xa inhibitors, especially apixaban. In addition, treatment with a vitamin K antagonist, in spite of any antiplatelet agent use, decreased from 35.63% in 2010-2012 to 11.12% in 2019-2021 (-24.48%, P < 0.0001), as well as any antiplatelet therapy, alone or in double combination, (49.18% in 2010-2012 vs 34.18% in 2019-2021, -15.00%, P < 0.0001); and patients not receiving antithrombotic therapy declined with time (14.58% in 2010-2012 vs 1.97% in 2021, P < 0.0001).

CONCLUSION

Real-world patients with AF are elderly and affected by cardiovascular and non-cardiovascular diseases. The percentage of patients on OAT and DOACs increased. These data suggest a slow, gradual guidelines implementation process.

Prevalence, risk factors, and prediction of inappropriate use of non-vitamin K antagonist oral anticoagulants in elderly Chinese patients with atrial fibrillation: A study protocol

Background

Atrial fibrillation (AF) is an arrhythmia that is prevalent globally, and its incidence grows exponentially with aging. Non-vitamin K antagonist oral anticoagulants (NOACs) have been developed in recent years, and it challenges the supremacy of warfarin for thromboembolism prophylaxis in AF. Nevertheless, there are limited data specifically evaluating the real-life use of NOACs in elderly patients with AF in China.

Methods

This is a national, multicenter, non-interventional, cross-sectional study that enrolls patients with AF aged 75 years and above from 31 institutions across China. Data were collected using the Hospital Information System. The primary outcomes include (1) profiles of NOAC use in the elderly; (2) frequency of inappropriate NOAC use based on guidelines and approved labeling recommendations; (3) exploring potential risk factors related to NOACs inappropriate use; and (4) creating a prediction tool for inappropriate NOACs use.

Conclusion

The results of this study reveal the prevalence, risk factors, and corresponding prediction tool of inappropriate NOACs use in older patients with AF in China, as well as provide valuable insights into the clinical application of NOACs in high-risk populations in the real-world setting.

Clinical trial registration

www.ClinicalTrials.gov, identifier: NCT 05361889.

Evolving Antithrombotic Treatment Patterns for Patients With Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome or Underwent Percutaneous Coronary Intervention in China: A Cross-Sectional Study

Objective

Antithrombotic therapy in patients with nonvalvular atrial fibrillation (NVAF) concomitant with the acute coronary syndrome (ACS) or underwent percutaneous coronary intervention (PCI) is challenging and has evolved in recent years. However, real-world data on this issue about antithrombotic regimens at discharge and its evolving trend were relatively scarce, especially in China.

Methods

A total of 2,182 patients with NVAF and ACS/PCI were enrolled from 2017 to 2019. A total of 1,979 patients were finally analyzed and divided in three sequential cohorts: cohort 1 (2017), n = 674; cohort 2 (2018), n = 793; and cohort 3 (2019), n = 512. Baseline characteristics and antithrombotic therapy at discharge were analyzed by cohort.

Results

In our cross-sectional study, the majority of patients (59.6%) received dual antiplatelet therapy (DAPT). Over the 3 years, DAPT prescription reduced from nearly 70% to <50% (P trend < 0.001), while triple therapy (TT)/double therapy (DT) increased from 27.2 to 50.0% (P trend < 0.001). This trend was also seen in different subgroups stratified by CHA2DS2-VASc score, HAS-BLED score, coronary artery disease type, or management type, and was validated after multivariate adjustment. Persistent atrial fibrillation and history of congestive heart failure, hypertension, diabetes mellitus, and stroke/transient ischemic attack/systemic embolism were the independent predictors of TT/DT use, while ACS, PCI, or advanced chronic kidney disease was related with more DAPT prescription.

Conclusion

There is a shift of antithrombotic regime at discharge for patients with NVAF with recent ACS/PCI with reducing DAPT prescription and increasing TT/DT prescription. While the appropriate antithrombotic regimen for patients with NVAF having ACS/PCI is still underused in China.