Patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention
(PCI) are at elevated risk for bleeding and thromboembolic ischemic events. Currently,
guidelines on antithrombotic treatment for these patients are based on weak consensus.
We describe patterns and determinants of antithrombotic prescriptions in this population.
The Antithrombotic Strategy Variability in Atrial Fibrillation and Obstructive Coronary
Disease Revascularized with PCI Registry was an international observational study
of 859 consecutive patients with AF who underwent PCI from 2009 to 2011. Patients
were stratified by treatment at discharge with either dual antiplatelet therapy (DAPT;
aspirin plus clopidogrel) or triple therapy (TT; warfarin plus DAPT). Bleeding and
thromboembolism risks were assessed by the HAS-BLED and CHADS2 scores, respectively, and predictors of TT prescription at discharge were identified.
Major adverse cardiovascular events and clinically relevant bleeding (Bleeding Academic
Research Consortium score ≥2) at 1-year follow-up were compared across antithrombotic
regimens. Compared with patients on DAPT (n = 488; 57%), those given TT (n = 371;
43%) were older, with higher CHADS2 scores, lower left ventricular ejection fraction, and more often had permanent AF,
single-vessel coronary artery disease, and bare-metal stents. In multivariate analysis,
increasing thromboembolic risk (CHADS2) was associated with a higher rate of TT prescription at discharge (intermediate
vs low CHADS2: odds ratio 2.2, 95% confidence interval [CI] 2.0 to 3.3, p <0.01; high vs low CHADS2: odds ratio 1.6, 95% CI 2.6 to 4.3, p <0.01 for TT). However, there was no significant
association between bleeding risk and TT prescription in the overall cohort or within
each CHADS2 risk stratum. The rates of major adverse cardiovascular events were similar for patients
discharged on TT or DAPT (20% vs 17%, adjusted hazard ratio 0.8, 95% CI 0.5 to 1.1,
p = 0.19), whereas the rate of Bleeding Academic Research Consortium ≥2 bleeding was
higher in patients discharged on TT (11.5% vs 6.4%, adjusted hazard ratio 1.8, 95%
CI 1.1 to 2.9, p = 0.02). In conclusion, the choice of the intensity of antithrombotic
therapy correlated more closely with the risk of ischemic rather than bleeding events
in this cohort of patients with AF who underwent PCI.
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References
- Warfarin for the prevention of systemic embolism in patients with non-valvular atrial fibrillation: a meta-analysis.Heart. 2008; 94: 1607-1613
- Meta-analysis of trials comparing oral anticoagulation and aspirin versus dual antiplatelet therapy after coronary stenting. Clues for the management of patients with an indication for long-term anticoagulation undergoing coronary stenting.Cardiology. 2005; 104: 101-106
- Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention.J Am Coll Cardiol. 2013; 62: 981-989
- Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC).Eur Heart J. 2010; 31: 2369-2429
- Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines.Circulation. 2013; 127: 1916-1926
- Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective.Thromb Haemost. 2011; 106: 572-584
- Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting. A consensus document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association [EHRA] and the European Association of Percutaneous Cardiovascular Interventions [EAPCI].Thromb Haemost. 2010; 103: 13-28
- A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.Chest. 2010; 138: 1093-1100
- Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.JAMA. 2001; 285: 2864-2870
- Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium.Circulation. 2011; 123: 2736-2747
- Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial.Lancet. 2013; 381: 1107-1115
- Performance of the HEMORR(2)HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study.J Am Coll Cardiol. 2012; 60: 861-867
- Predictive value of the HAS-BLED and ATRIA bleeding scores for the risk of serious bleeding in a “real-world” population with atrial fibrillation receiving anticoagulant therapy.Chest. 2013; 143: 179-184
- Triple antithrombotic therapy versus double antiplatelet therapy after percutaneous coronary intervention with stent implantation in patients requiring chronic oral anticoagulation: a meta-analysis.Chin Med J (Engl). 2013; 126: 2536-2542
- Use of the CHA(2)DS(2)-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation.Circulation. 2012; 126: 860-865
- 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association.Eur Heart J. 2012; 33: 2719-2747
- Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis.J Am Coll Cardiol. 2008; 51: 818-825
- Antiplatelet therapy in patients with anticoagulants undergoing percutaneous coronary stenting (from STENTIng and oral antiCOagulants [STENTICO]).Am J Cardiol. 2009; 104: 338-342
- Aspirin and clopidogrel with or without phenprocoumon after drug eluting coronary stent placement in patients on chronic oral anticoagulation.J Intern Med. 2008; 264: 472-480
- Comparison of different antithrombotic regimens for patients with atrial fibrillation undergoing drug-eluting stent implantation.Circ J. 2010; 74: 701-708
- Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction.Am Heart J. 2012; 163: 720-728
- Warfarin use among older atrial fibrillation patients with non-ST-segment elevation myocardial infarction managed with coronary stenting and dual antiplatelet therapy.Am Heart J. 2013; 166: 864-870
- Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS).Eur Heart J. 2014; 35: 3155-3179
Article Info
Publication History
Published online: April 07, 2015
Accepted:
March 24,
2015
Received in revised form:
March 24,
2015
Received:
January 9,
2015
Footnotes
See page 41 for disclosure information.
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
