Antithrombotic management of atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing coronary stenting: executive summary--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)

Triple therapy for atrial fibrillation and percutaneous coronary intervention: a contemporary review

Chronic oral anticoagulant therapy is recommended (class I) in patients with mechanical heart valves and in patients with atrial fibrillation with a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or transient ischemic attack or thromboembolism, Vascular disease, Age 65 to 74 years, Sex category) score ≥1. When these patients undergo percutaneous coronary intervention with stenting, treatment with aspirin and a P2Y12 receptor inhibitor also becomes indicated. Before 2014, guidelines recommended the use of triple therapy (vitamin K antagonists, aspirin, and clopidogrel) for these patients. However, major bleeding is increasingly recognized as the Achilles' heel of the triple therapy regimen. Lately, various studies have investigated this topic, including a prospective randomized trial, and the evidence for adding aspirin to the regimen of vitamin K antagonists and clopidogrel seems to be weakened. In this group of patients, the challenge is finding the optimal equilibrium to prevent thromboembolic events, such as stent thrombosis and thromboembolic stroke, without increasing bleeding risk.

Antithrombotic triple therapy and coagulation activation at the site of thrombus formation: a randomized trial in healthy subjects

BACKGROUND

Patients with acute coronary syndrome and concomitant atrial fibrillation may require antithrombotic triple therapy but clinical evidence of safety and efficacy is poor. We have therefore studied the combination of different antithrombotic medicines for coagulation activation in an in vivo model in the skin microvasculature.

METHODS AND RESULTS

Platelet activation (β-thromboglobulin [β-TG]) and thrombin generation (prothrombin fragment 1 + 2 [F1+2 ], thrombin-antithrombin complex [TAT]) were studied in an open-label, randomized, parallel group trial in 60 healthy male subjects (n = 20 per group) who received ticagrelor and acetylsalicylic acid (ASA) in combination with dabigatran (150 mg bid), rivaroxaban (20 mg od) or phenprocoumon (INR 2.0-3.0). Coagulation biomarkers in shed blood were assessed at 3 h after monotherapy with the medicines under study, at 3 h after triple therapy dosing and at steady state trough conditions. Single doses of ticagrelor, dabigatran or rivaroxaban caused comparable decreases in shed blood β-TG and were more pronounced than phenprocoumon at an INR of 2.0-3.0. In contrast, thrombin generation was more affected by rivaroxaban and phenprocoumon than by dabigatran. During triple therapy a similarly sustained inhibition of platelet activation and thrombin generation with a maximum decrease of β-TG, F1+2 and TAT at 3 h post-dosing was noted, which remained below pre-dose levels at trough steady state.

CONCLUSION

A triple therapy at steady state with ticagrelor plus ASA in combination with dabigatran or rivaroxaban is as effective as a combination with phenprocoumon for platelet activation and thrombin generation in vivo.

Evolving antithrombotic strategies in patients with atrial fibrillation undergoing percutaneous coronary intervention: results from a survey among US cardiologists

BACKGROUND

Many patients treated with oral anticoagulants for atrial fibrillation undergo percutaneous stent implantation, where dual antiplatelet therapy (DAPT) is also recommended. The current evidence to support triple oral antithrombotic therapy (TOAT) in these patients is limited, and new strategies are being discussed to optimize outcomes.

HYPOTHESIS

There will be variation in antithrombotic strategies in patients with atrial fibrillation needing stenting.

METHODS

We surveyed US-based cardiologists serving as clinical investigators in academic sites and posted an online "question of the month" on cardiosource.org.

RESULTS

Seventy-five (10.7%) responses were received to the email survey and 119 to the online question. Bare-metal stenting (BMS) was a priori preferred over drug-eluting stenting (DES) for 50.6% of patients. Only 8.8% of the responders chose newer anticoagulants in addition to DAPT as the preferred oral anticoagulant. For duration of TOAT, 79.4% of physicians recommended stopping DAPT at 1 month when BMS was used in patients presenting without acute coronary syndrome (ACS) vs 57.4% in patients with ACS. In patients implanted with a DES, 73.5% and 76.5% preferred stopping DAPT at 6 to 12 months (no ACS vs ACS, respectively). When asked which of the 2 antiplatelet agents they would recommend stopping after the above durations, 50% chose to quit aspirin.

CONCLUSIONS

The survey highlights an interest in the new strategy of dropping aspirin, but the lack of concrete evidence triggers undesired diversity in clinical approaches. High-quality data on the efficacy and safety of such interventions are needed to further consolidate these approaches.

[Consensus statement: Stroke prevention in nonvalvular atrial fibrillation in special consideration of the new direct oral anticoagulants]

The introduction of new direct oral anticoagulants has changed the treatment of nonvalvular atrial fibrillation. However, these changes are not yet fully reflected in current guidelines.This consensus statement, endorsed by six Austrian medical societies, provides guidance to current prophylactic approaches of thromboembolic events in nonvalvular atrial fibrillation on the basis of current evidence and published guidelines. Furthermore, some special subjects are treated, like changes in laboratory parameters and their interpretation under treatment with direct oral anticoagulants, treatment of bleedings, approach to operations, cardioversion and ablation, and specific neurological aspects. For a CHA2DS2-VASc-Score of ≥ 2, anticoagulation is recommended with a high level of evidence (1A). At the end of the consensus statement, recommendations for a number of specific patient subgroups can be found, in order to help treating physicians to arrive at appropriate therapeutic decisions.

Safety of coronary angiography and percutaneous coronary intervention via the radial versus femoral route in patients on uninterrupted oral anticoagulation with warfarin

OBJECTIVE

To evaluate access site and other bleeding complications associated with radial versus femoral access in patients receiving oral anticoagulation (OAC) with warfarin.

BACKGROUND

Patients receiving OAC with warfarin undergoing coronary angiography and percutaneous coronary intervention (PCI) may have OAC continued despite the risk of bleeding. To what extent arterial access site impacts bleeding in such patients is not well studied.

METHODS

Over 6 years, we identified 255 consecutive patients in whom warfarin was continued who underwent coronary angiography with an international normalized ratio >1.8. A total of 97 patients also underwent PCI at the same setting (27% femoral vs 73% radial). The primary outcome was Bleeding Academic Research Consortium bleeds; a secondary end point was frequency of access site complications in the 72 hours post-PCI. Complications were evaluated based on the initial access site attempted.

RESULTS

Minimal baseline clinical characteristics differences existed between the groups. International normalized ratio was significantly higher in the radial group (2.42 ± 0.67 vs 2.24 ± 0.49, P = .02). Bivalirudin use was greater during radial PCI than femoral (76% vs 42%, P < .05), whereas unfractionated heparin alone was greater during femoral PCI than radial (46% vs 18%, P < .05). No significant difference was seen in the primary end point between femoral (2.8%) and radial (1.6%, P = .54) during coronary angiography alone. However, PCI via the femoral artery had significantly more Bleeding Academic Research Consortium bleeding (19.2% vs 1.4%, P = .005) and transfusions (15% vs 0%, P = .004) than via the radial artery. Patients who underwent PCI using radial access were less likely to have any vascular or bleeding complications (1% vs 23%, P = .001).

CONCLUSIONS

Patients who underwent coronary angiography during uninterrupted OAC had similar bleeding rates regardless of access site. However, when PCI was performed, radial access was associated with fewer bleeding and vascular complications than the femoral approach.

CONDENSED ABSTRACT

We retrospectively identified 255 consecutive patients on warfarin who underwent coronary angiography, 97 of whom underwent a percutaneous coronary intervention. The data reveal a reduction in Bleeding Academic Research Consortium bleeds (1.6% vs 8.1%, P = .02) with radial versus femoral access. The radial approach was associated with an overall lower rate of any vascular or bleeding complication than the femoral approach during percutaneous coronary intervention (1% vs 23%, P = .001).

Optimizing selection of antithrombotic therapy in patients requiring PCI and long term anticoagulation

There remains clinical equipoise in the appropriate selection of antiplatelet therapy for the patient on long-term anticoagulation requiring percutaneous coronary intervention. Since most of these patients represent an increasingly aging population, the significant risk of thromboembolism and stent thrombosis must be weighed against the risk of major bleeding. This article reviews the current state of evidence to provide a framework for the practicing clinician.

Safety and efficacy of switching anticoagulation to aspirin three months after successful radiofrequency catheter ablation of atrial fibrillation

PURPOSE

Although current guidelines recommend continuing the same antithrombotic strategy regardless of rhythm control after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF), anticoagulation has a risk of major bleeding. We evaluated the safety of switching warfarin to aspirin in patients with successful AF ablation.

MATERIALS AND METHODS

Among 721 patients who underwent RFCA of AF, 608 patients (age, 57.3±10.9 years; 77.0% male, 75.5% paroxysmal AF) who had no evidence of AF recurrence at 3 months post-RFCA were included. We compared the thromboembolic and hemorrhagic events in patients for whom warfarin was switched to aspirin (ASA group; n=296) and patients who were kept on warfarin therapy (W group; n=312).

RESULTS

There were no significant differences in CHA₂DS₂-VASc or HAS-BLED scores between the groups. In 30 patients in the ASA group and 37 patients in W group, AF recurred and warfarin was restarted or maintained during the 18.0±12.2 months of follow-up. There were no significant differences in thromboembolic (0.3% vs. 1.0%, p=0.342) and major bleeding incidences (0.7% vs. 0.6%, p=0.958) between ASA and W groups during the follow-up period. In the 259 patients with a CHA₂DS₂-VASc score≥2, there were no significant differences in thromboembolism (0.8% and 2.2%, p=0.380) or major bleeding incidences (0.8% and 1.4%, p=0.640) between ASA and W groups.

CONCLUSION

Switching warfarin to aspirin 3 months after successful RFCA of AF could be as safe and efficacious as long-term anticoagulation even in patients with CHA₂DS₂-VASc score≥2. However, strict rhythm monitoring cannot be overemphasized.

Atrial fibrillation and coronary artery disease: which antithrombotic treatment strategy?

PURPOSE OF REVIEW

The optimal antithrombotic therapy in patients with atrial fibrillation and coronary artery disease is controversial. The benefit of the combination of antithrombotic therapies remains debatable, and, as the bleeding risk is substantial, this calls for knowledge of the duration, and which and how many agents should be used.

RECENT FINDINGS

The first randomized trial to challenge current recommendations of triple therapy (oral anticoagulation plus clopidogrel plus aspirin) examined patients on warfarin undergoing percutaneous coronary intervention with stent implantation. A reduced risk of any bleeding (hazard ratio 0.36) was found with combination of clopidogrel compared with triple therapy without increasing major cardiovascular events. In real-life patients, a nationwide Danish registry supported these findings, and, relative to triple therapy, no significant difference was found for recurrent myocardial infarction when adding only clopidogrel (hazard ratio 0.69) or aspirin (hazard ratio 0.96) to vitamin K antagonist. However, the latter regimen was associated with significantly increased risk of death.

SUMMARY

Within 1 year after myocardial infarction and/or percutaneous coronary intervention in patients with atrial fibrillation, current consensus papers endorse use of dual antiplatelet therapy on top of oral anticoagulation. A regimen consisting of oral anticoagulation and clopidogrel (without aspirin) could provide an alternative from a benefit and safety perspective.

CONTEMPORARY APPROACHES TO ANTIPLATELET THERAPY IN CORONARY HEART DISEASE TREATMENT

Transcutaneous interventions (PCI) are in growing usage as a method to revascularize myocardium in coronary heart disease. Double antiplatelet therapy, including acetylsalicylic acid clopidogrel, is now routinely prescribed for CHD patients preparing to undergo coronary intervention to prevent thrombosis. Reaching the maximum advantage in double antiplatelet therapy with control of platelet function after PCI may have additional value in cardiovascular morbidity and mortality prevention. 

Outcome after coronary artery bypass surgery and percutaneous coronary intervention in patients with atrial fibrillation and oral anticoagulation

AIM

This study was planned to compare the clinical characteristics and outcome of patients on warfarin treatment for atrial fibrillation (AF) undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).

METHODS

This is a retrospective analysis of 121 patients who underwent isolated CABG and 301 patients who underwent PCI.

RESULTS

PCI patients were older (mean age, 72.9 versus 69.8 years) and more often had prior cardiac surgery (15.9% versus 1.7%) and acute coronary syndrome (53.8% versus 21.5%). CABG patients more often had two- and three-vessel disease (95.0% versus 60.2%) and left main stenosis (32.2% versus 7.0%). The 30-day outcome was similar after PCI and CABG. At 3 years, PCI was associated with lower overall survival (72.0% versus 86.4%, P = 0.006), freedom from repeat revascularization (85.3% versus 98.2%, P < 0.001), freedom from myocardial infarction (83.4% versus 93.8%, P = 0.008), and freedom from major cardiovascular events (57.4% versus 78.9%, P < 0.001). Propensity score adjusted analysis showed that PCI was associated with increased risk of all-cause mortality (P = 0.016, RR 2.166, CI 1.155-4.060), myocardial infarction (P = 0.017, RR 3.161, 95% CI 1.227-8.144), repeat revascularization (P = 0.001, RR 13.152, 95% CI 2.799-61.793), and major cardiac and cerebrovascular complications (P = 0.001, RR 2.347, 95% CI 1.408-3.914). There was no difference in terms of stroke and bleeding episodes at any time point.

CONCLUSION

In clinical practice, PCI is the preferred revascularization strategy in these frail patients. Patients selected for CABG have a relatively low operative risk and better mid-term outcome in spite of warfarin treatment. The poor prognosis after PCI may mainly reflect frequent co-morbidities in this patient group.

Performance of bleeding risk-prediction scores in patients with atrial fibrillation undergoing percutaneous coronary intervention

The hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, and drugs/alcohol (HAS-BLED); anticoagulation and risk factors in atrial fibrillation (ATRIA); modified Outpatient Bleeding Risk Index (mOBRI); and reduction of atherothrombosis for continued health (REACH) schemes are validated bleeding risk-prediction tools, but their predictive performance in patients with AF receiving multiple antithrombotic drugs after percutaneous coronary intervention (PCI) is unknown. We sought to compare the predictive performance of bleeding risk-estimation tools in a cohort of patients with atrial fibrillation (AF) undergoing PCI. Management of patients with AF undergoing coronary artery stenting is a multicenter European prospective registry enrolling patients with AF undergoing PCI. We calculated HAS-BLED, ATRIA, mOBRI, and REACH bleeding risk-prediction scores and assessed the rate of bleeding complications as defined by Bleeding Academic Research Consortium at 12 months follow-up in 929 consecutive patients undergoing PCI. Increasing age, femoral access site, and previous peptic ulcer were independent determinants of bleeding. Low bleeding risk scores as determined by HAS-BLED 0 to 2, ATRIA 0 to 3, mOBRI 0, and REACH 0 to 10 were detected in 23.7%, 73.0%, 7.8%, and 5.7% of patients of the cohort, respectively. No significant differences were detected in the rates of any bleeding or major bleeding events for low versus intermediate/high scores with each risk-prediction tool. In conclusion, the performance of ATRIA, HAS-BLED, mOBRI, and REACH scores in predicting bleeding complications in this high-risk patient subset was useless.

Impact of anaemia on clinical outcome in patients with atrial fibrillation undergoing percutaneous coronary intervention: insights from the AFCAS registry

OBJECTIVES

Anaemia has an adverse impact on the outcome in the general patient population undergoing percutaneous coronary intervention (PCI). The aim of this study was to analyse the impact of anaemia on the 12-month clinical outcome of patients with atrial fibrillation (AF) undergoing PCI and therefore requiring intense antithrombotic treatment. We hypothesised that anaemia might be associated with a worse outcome and more bleeding in these anticoagulated patients.

SETTING

Data were collected from 17 secondary care centres in Europe.

PARTICIPANTS

Consecutive patients with AF undergoing PCI were enrolled in the prospective, multicenter AFCAS (Atrial Fibrillation undergoing Coronary Artery Stenting) registry. Altogether, 929 patients participated in the study. Preprocedural haemoglobin concentration was available for 861 (92.7%; 30% women). The only exclusion criteria were inability or unwillingness to give informed consent. Anaemia was defined as a haemoglobin concentration of <12 g/dL for women and <13 g/dL for men.

OUTCOME MEASURES

The primary endpoint was occurrence of major adverse cardiac and cerebrovascular events (MACCE) or bleeding events.

RESULTS

258/861 (30%) patients had anaemia. Anaemic patients were older, more often had diabetes, higher CHA2DS2-VASc scores, prior history of heart failure, chronic renal impairment and acute coronary syndrome. Anaemic patients had more MACCE than non-anaemic (29.1% vs 19.4%, respectively, p=0.002), and minor bleeding events (7.0% vs 3.3%, respectively, p=0.028), with a trend towards more total bleeding events (25.2% vs 21.7%, respectively, p=0.059). No difference was observed in antithrombotic regimens at discharge. In multivariate analysis, anaemia was an independent predictor of all-cause mortality at 12-month follow-up (hazard ratio 1.62, 95% CI 1.05 to 2.51, p=0.029).

CONCLUSIONS

Anaemia was a frequent finding in patients with AF referred for PCI. Anaemic patients had a higher all-cause mortality, more thrombotic events and minor bleeding events. Anaemia seems to be an identification of patients at risk for cardiovascular events and death.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT00596570.

Unanswered questions in patients with concurrent atrial fibrillation and acute coronary syndrome

The best regimen for the long-term management of patients with atrial fibrillation who present with an acute coronary syndrome or require placement of a coronary stent remains unclear. Clinicians need to understand the risk of stroke, stent thrombosis, and major bleeding associated with treating these patients. Numerous studies and risk assessment schemes provide clinicians with an estimation of the risk of stroke, stent thrombosis, and major bleeding that may be associated with the use or avoidance of dual antiplatelet therapy with concurrent anticoagulation therapy (triple therapy). This review discusses the special antithrombotic needs in patients who have atrial fibrillation and either acute coronary syndrome or a requirement for percutaneous coronary intervention, including the published evidence for non-vitamin K oral anticoagulants, and the unanswered questions in this patient population. In conclusion, until the results of additional ongoing or planned randomized trials are known, clinicians must continue to rely on expert opinion and their own clinical judgment when treating these patients.

Antiplatelet therapy for stable coronary artery disease in atrial fibrillation patients taking an oral anticoagulant: a nationwide cohort study

BACKGROUND

The optimal long-term antithrombotic treatment of patients with coexisting atrial fibrillation and stable coronary artery disease is unresolved, and commonly, a single antiplatelet agent is added to oral anticoagulation. We investigated the effectiveness and safety of adding antiplatelet therapy to vitamin K antagonist (VKA) in atrial fibrillation patents with stable coronary artery disease.

METHODS AND RESULTS

Atrial fibrillation patients with stable coronary artery disease (defined as 12 months from an acute coronary event) between 2002 and 2011 were identified. The subsequent risk of cardiovascular events and serious bleeding events (those that required hospitalization) was examined with adjusted Cox regression models according to ongoing antithrombotic therapy. A total of 8700 patients were included (mean age, 74.2 years; 38% women). During a mean follow-up of 3.3 years, crude incidence rates were 7.2, 3.8, and 4.0 events per 100 person-years for myocardial infarction/coronary death, thromboembolism, and serious bleeding, respectively. Relative to VKA monotherapy, the risk of myocardial infarction/coronary death was similar for VKA plus aspirin (hazard ratio, 1.12 [95% confidence interval, 0.94-1.34]) and VKA plus clopidogrel (hazard ratio, 1.53 [95% confidence interval, 0.93-2.52]). The risk of thromboembolism was comparable in all regimens that included VKA, whereas the risk of bleeding increased when aspirin (hazard ratio, 1.50 [95% confidence interval, 1.23-1.82]) or clopidogrel (hazard ratio, 1.84 [95% confidence interval, 1.11-3.06]) was added to VKA.

CONCLUSIONS

In atrial fibrillation patients with stable coronary artery disease, the addition of antiplatelet therapy to VKA therapy is not associated with a reduction in risk of recurrent coronary events or thromboembolism, whereas risk of bleeding is increased significantly. The common practice of adding antiplatelet therapy to oral VKA anticoagulation in patients with atrial fibrillation and stable coronary artery disease warrants reassessment.

Frequency of radial artery occlusion after transradial access in patients receiving warfarin therapy and undergoing coronary angiography

The efficacy of warfarin-induced anticoagulation in reducing radial artery occlusion (RAO) after transradial access is not known. The present case-control study compared the incidence of early (24 hours) and late (30 days) RAO in patients undergoing transradial diagnostic coronary angiography during therapeutic warfarin anticoagulation (group 1) with that of a matched (3:1) cohort of patients not receiving warfarin and receiving intraprocedural heparin (group 2). All patients underwent transradial diagnostic coronary angiography using a 5F hydrophilic introducer sheath. The patients in group 2 received an intravenous heparin bolus (50 IU/kg) immediately after sheath insertion. After sheath removal, hemostasis was obtained using the TR-band (Terumo Interventional Systems, Terumo Medical, Tokyo, Japan) and a plethysmography-guided patent hemostasis technique. We included 86 patients receiving warfarin with an international normalized ratio of 2 to 4 in group 1 and 250 matched patients in group 2. No significant differences were present in the demographic and procedural variables between the 2 groups. Early RAO occurred in 18.6% of the patients in group 1 compared with 9.6% of patients in group 2 (p = 0.024). The incidence of late RAO remained significantly higher in group 1 compared with group 2 (13.9% vs 5.2%, p = 0.01). All patients with RAO remained asymptomatic. In conclusion, patients receiving chronic oral anticoagulation with warfarin and undergoing transradial coronary angiography without parenteral anticoagulation had a higher incidence of early and late RAO compared with patients receiving standard intravenous heparin therapy.

Practical considerations for using novel oral anticoagulants in patients with atrial fibrillation

Novel oral anticoagulants, including dabigatran, rivaroxaban, and apixaban, represent new options for preventing stroke in patients with atrial fibrillation, as shown by the results from large, randomized phase III trials. Because of their greater specificity, rapid onset of action, and predictable pharmacokinetics, the novel oral anticoagulants (dabigatran, rivaroxaban, and apixaban) address several limitations of warfarin or other vitamin K antagonists in day-to-day clinical practice. However, a range of practical questions relating to the novel oral anticoagulants has emerged, including topics such as patient selection, treatment of patients with renal impairment, risk of myocardial infarction, drug interactions, switching between anticoagulants, and management of bleeding, in addition to use of these agents in patients requiring antiplatelet drug treatment or undergoing cardioversion or percutaneous interventions (eg, ablation). In this review, practical aspects of the use of novel oral anticoagulants in patients with atrial fibrillation are discussed, with reference to available data and guidance from prescribing information.

Combined use of warfarin and oral P2Y12 inhibitors in patients with atrial fibrillation and acute coronary syndrome

BACKGROUND

Although atrial fibrillation (AF) occurs frequently in patients hospitalized with acute coronary syndrome (ACS), strategies for prevention of thromboembolic complications are poorly characterized.

HYPOTHESIS

We sought to examine exposure to warfarin and P2Y12 inhibitors and clinical outcomes among patients with AF and ACS.

METHODS

Patients age >65 years hospitalized with a primary diagnosis of ACS and a secondary diagnosis of AF between 2007 and 2010 were identified in the Medicare 5% sample. Medication exposure was ascertained during a 90-day period following the index discharge using Medicare drug claims. Among patients who were alive and not readmitted during the ascertainment period, we examined the cumulative incidence of all-cause mortality and all-cause readmission by medication exposure at 1 year.

RESULTS

A total of 2509 Medicare beneficiaries met the inclusion criteria. Among the 1633 patients (65%) who were alive and not readmitted during the 90-day ascertainment period, 24.0% received warfarin, 38.9% received P2Y12 inhibitors, 10.2% received combination therapy, and 26.8% received neither therapy. Readmission rates were high in all groups at 1 year (warfarin, 47.5%; P2Y12 inhibitors, 46.6%; combination therapy, 38.0%; and neither therapy, 39.3%), and the overall 1-year mortality rate was 12.5%.

CONCLUSIONS

Among Medicare beneficiaries with AF and ACS, combination therapy with warfarin and P2Y12 inhibitor was uncommon during the 90-day ascertainment period, and more than one-quarter of patients had no claims for warfarin or P2Y12 inhibitors. Rates of all-cause readmission and mortality within 1 year of hospitalization for ACS were high.

Vitamin K antagonists in heart disease: current status and perspectives (Section III). Position paper of the ESC Working Group on Thrombosis--Task Force on Anticoagulants in Heart Disease

Oral anticoagulants are a mainstay of cardiovascular therapy, and for over 60 years vitamin K antagonists (VKAs) were the only available agents for long-term use. VKAs interfere with the cyclic inter-conversion of vitamin K and its 2,3 epoxide, thus inhibiting γ-carboxylation of glutamate residues at the amino-termini of vitamin K-dependent proteins, including the coagulation factors (F) II (prothrombin), VII, IX and X, as well as of the anticoagulant proteins C, S and Z. The overall effect of such interference is a dose-dependent anticoagulant effect, which has been therapeutically exploited in heart disease since the early 1950s. In this position paper, we review the mechanisms of action, pharmacological properties and side effects of VKAs, which are used in the management of cardiovascular diseases, including coronary heart disease (where their use is limited), stroke prevention in atrial fibrillation, heart valves and/or chronic heart failure. Using an evidence-based approach, we describe the results of completed clinical trials, highlight areas of uncertainty, and recommend therapeutic options for specific disorders. Although VKAs are being increasingly replaced in most patients with non-valvular atrial fibrillation by the new oral anticoagulants, which target either thrombin or FXa, the VKAs remain the agents of choice for patients with atrial fibrillation in the setting of rheumatic valvular disease and for those with mechanical heart valves.

Dual antiplatelet therapy with prasugrel or ticagrelor versus clopidogrel in interventional cardiology

For several years, clopidogrel plus aspirin has been the dual antiplatelet therapy (DAPT) of choice for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) with stent implantation. More recently, prasugrel and ticagrelor have demonstrated greater efficacy than clopidogrel. In TRITON-TIMI 38, the risk of TIMI major bleeding unrelated to coronary artery bypass graft (CABG) surgery was similar for prasugrel and clopidogrel after excluding subgroups with increased bleeding risk (previous stroke or transient ischemic event; age ≥75 years; weight <60 kg). In the PLATO trial, rates of TIMI major bleeding were similar for ticagrelor and clopidogrel, but ticagrelor was associated with a significantly higher rate of non-CABG-related TIMI major bleeding. Current evidence suggests that prasugrel or ticagrelor plus aspirin should be the DAPT of choice in patients with ACS undergoing PCI unless they are at particularly high risk of bleeding. No studies have yet compared prasugrel and ticagrelor in ACS patients, however prasugrel and ticagrelor have different side effect profiles, and the choice of agent should be made either as a default choice and/or on an individual patient basis. Ongoing trials in ACS patients will increase the evidence base for new P2Y(12) receptor inhibitors and help to establish the most effective DAPT regimens.

Warfarin use among older atrial fibrillation patients with non-ST-segment elevation myocardial infarction managed with coronary stenting and dual antiplatelet therapy

BACKGROUND

We sought to determine the risk of readmission for bleeding and major cardiac events in stented non-ST-segment elevation myocardial infarction (NSTEMI) atrial fibrillation (AF) patients.

METHODS

For this patient population, selection of an antithrombotic strategy poses a unique challenge in clinical practice, and comparative outcome data are sparse. We linked NSTEMI patients aged ≥ 65 years in the CRUSADE Registry (2003-2006) to Medicare claims data. We examined patients with AF who received coronary stenting and either dual antiplatelet therapy (DAPT, aspirin + clopidogrel) or triple therapy (DAPT + warfarin) upon discharge. Multivariable Cox analysis was used to compare the 1-year risks of major cardiac events and readmission for bleeding.

RESULTS

We identified 1,648 stented NSTEMI AF patients. Of these, 1,200 (73%) received DAPT, and 448 (27%) received triple therapy at hospital discharge. Predicted thromboembolic and bleeding risks did not appear to influence the decision to receive DAPT or triple therapy. At 1 year, 20.4% had a major cardiac event, and 13.5% were admitted for bleeding. Use of triple therapy relative to DAPT at discharge was associated with a similar adjusted risk of major cardiac events (adjusted hazard ratio 0.94, CI 0.73-1.21) but a trend toward increased risk of readmission for bleeding (hazard ratio 1.29, CI 0.96-1.74, P = .09).

CONCLUSIONS

In routine practice and in contrast with practice recommendations, most elderly NSTEMI patients with AF who undergo percutaneous coronary intervention with stent placement receive DAPT rather than triple therapy at discharge. Those receiving triple therapy versus DAPT had a similar risk of an ischemic event but a trend toward increased bleeding.

Ischaemic cardiac outcomes in patients with atrial fibrillation treated with vitamin K antagonism or factor Xa inhibition: results from the ROCKET AF trial

AIMS

We investigated the prevalence of prior myocardial infarction (MI) and incidence of ischaemic cardiovascular (CV) events among atrial fibrillation (AF) patients.

METHODS AND RESULTS

In ROCKET AF, 14 264 patients with nonvalvular AF were randomized to rivaroxaban or warfarin. The key efficacy outcome for these analyses was CV death, MI, and unstable angina (UA). This pre-specified analysis was performed on patients while on treatment. Rates are per 100 patient-years. Overall, 2468 (17%) patients had prior MI at enrollment. Compared with patients without prior MI, these patients were more likely to be male (75 vs. 57%), on aspirin at baseline (47 vs. 34%), have prior congestive heart failure (78 vs. 59%), diabetes (47 vs. 39%), hypertension (94 vs. 90%), higher mean CHADS2 score (3.64 vs. 3.43), and fewer prior strokes or transient ischaemic attacks (46 vs. 54%). CV death, MI, or UA rates tended to be lower in patients assigned rivaroxaban compared with warfarin [2.70 vs. 3.15; hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.73-1.00; P = 0.0509]. CV death, MI, or UA rates were higher in those with prior MI compared with no prior MI (6.68 vs. 2.19; HR 3.04, 95% CI 2.59-3.56) with consistent results for CV death, MI, or UA for rivaroxaban compared with warfarin in prior MI compared with no prior MI (P interaction = 0.10).

CONCLUSION

Prior MI was common and associated with substantial risk for subsequent cardiac events. Patients with prior MI assigned rivaroxaban compared with warfarin had a non-significant 14% reduction of ischaemic cardiac events.

Drug eluting stent implantation in patients requiring concomitant vitamin K antagonist therapy. One-year outcome of the worldwide e-SELECT registry

BACKGROUND

Outcome of sirolimus-eluting stent (SES) in patients treated with an antivitamin K (VKA) agent before the PCI procedure is unknown.

METHODS

A total of 7651 patients were selected among 15,147 recipients of SES, included in the worldwide e-SELECT registry, only from those centers which included at least one patient requiring VKA: 296 were pretreated with a VKA agent (VKA group), whereas 7355 patients from the same enrolling medical centers were not (NON-VKA group). The rates of 1) major adverse cardiac events (MACE), including all-cause deaths, myocardial infarction (MI) and target lesion revascularization, 2) stent thrombosis (ST) and 3) major bleeding (MB) in the 2 study groups were compared at 1, 6 and 12 months.

RESULTS

The patients in VKA group were on average older as compared to those in NON-VKA group (67.7 ± 9.9 vs.62.9 ± 10.7, P<0.001). The indications for pre-procedural anticoagulation were atrial fibrillation in 177 (59.8%), presence of a prosthetic valve in 21 (7.1%), embolization of cardiac origin in 17 (5.7%), pulmonary embolism or deep vein thrombosis in 17 (5.7%), and miscellaneous diagnoses in 64 (21.6%) patients. At 1 year, the rates of MACE and MB were higher in the VKA vs. the NON-VKA group (8.3% and 3% vs. 5.3% and 1.2%, P<0.04 and P<0.002, respectively). The 1-year rates of definite and probable ST were remarkably low in both groups (0.38% vs. 1.1%, p=0.4).

CONCLUSIONS

Selected patients anticoagulated with VKA agent may safely undergo SES implantation. Those patients may receive a variety of APT regimen at the cost of a moderate increased risk of MB.

Triple Antiplatelet Therapy and Combinations with Oral Anticoagulants After Stent Implantation

Triple oral anticoagulation or triple antiplatelet therapies may be administered for various reasons. They reduce cardiac complications following percutaneous coronary intervention and stroke or other thromboembolic phenomenon in conditions such as atrial fibrillation. There is an elevated risk of severe bleeding, so it is necessary to balance risk and benefits. Newer oral anticoagulants and antiplatelet drugs may be considered; the number of options is increasing. This article examines triple therapies and the efficacy and safety of combinations of traditional anticoagulant and antiplatelet drugs, and reviews clinical trial data on novel agents. Guidelines to inform clinical decision-making are presented.

Clinical review: bleeding - a notable complication of treatment in patients with acute coronary syndromes: incidence, predictors, classification, impact on prognosis, and management

This article focuses on the incidence, predictors, classification, impact on prognosis, and management of bleeding associated with the treatment of acute coronary syndrome. The issue of bleeding complications is related to the continual improvement of ischemic heart disease treatment, which involves mainly (a) the widespread use of coronary angiography, (b) developments in percutaneous coronary interventions, and (c) the introduction of new antithrombotics. Bleeding has become an important health and economic problem and has an incidence of 2.0% to 17%. Bleeding significantly influences both the short- and long-term prognoses. If a group of patients at higher risk of bleeding complications can be identified according to known risk factors and a risk scoring system can be developed, we may focus more on preventive measures that should help us to reduce the incidence of bleeding.

Oral antiplatelet therapy in acute coronary syndromes: update 2012

Dual antiplatelet therapy (DAPT), usually consisting of clopidogrel and acetylsalicylic acid (ASA), has come into discussion in recent years due to an increasing number of major adverse cardiac events based on insufficient ADP-mediated platelet inhibition with clopidogrel, mainly explained by drug interactions or genetic variants slowing or hindering the bioactivation of the prodrug clopidgrel into an active metabolite. Accordingly, new antiplatelet agents like prasugrel and ticagrelor were investigated in large prospective randomized clinical trials in patients with different entities of acute coronary syndromes (ACS). Based on their beneficial results in comparison to clopidogrel, these agents have found their way into the recent international guidelines for treatment of patients with acute coronary syndromes. Both antiplatelet agents demonstrated superiority with respect to the primary composite endpoint (cardiovascular death/non-lethal myocardial infarction/stroke). Ticagrelor even exhibited a mortality benefit over the comparator, but both compounds also increased the risk of spontaneous major bleedings to a significant extent. However, the efficacy/safety ratio of prasugrel and ticagrelor compared to clopidogrel is better. This article widens the insight into the recent changes in antiplatelet therapy in ACS by discussing the clinically most important data derived from the TRITON-TIMI 38 trial and the PLATO trial, including also the retrospective and pre-defined subgroup analyses. This article also gives information about the recommended duration of DAPT and the situation when patients who need permanent anticoagulation (e.g. in case of non-valvular atrial fibrillation) deserve also DAPT after coronary stenting ('triple therapy').

Heart failure in patients with atrial fibrillation is associated with a high symptom and hospitalization burden: the RealiseAF survey

BACKGROUND

Atrial fibrillation (AF) and heart failure (HF) often coexist; the consequences of such coexistence are unclear.

HYPOTHESIS

HF in patients with AF is associated with poor outcomes.

METHODS

This post hoc analysis of RealiseAF, a survey of AF patients, compared symptoms, hospitalizations, management, and AF control in patients with vs without HF. A total of 10,523 AF patients were analyzed according to presence/absence of HF.

RESULTS

History of HF was present in 45.8%, and in more patients with permanent vs persistent, paroxysmal, or first-episode AF (55.6%, 44.3%, 32.9%, and 29.8%, respectively; P < 0.0001). Patients with vs those without history of HF, and patients with HF and reduced ejection fraction (HF-REF) vs those with HF and a preserved ejection fraction (HF-PEF), had more frequent cardiovascular (CV) risk factors and more severe symptoms. Presence vs absence of HF, and HF-REF vs HF-PEF, were associated with lower rates of AF control (54.6% vs 62.8% and 49.3% vs 60.3%, respectively; both P < 0.0001). The rate-control strategy was used more frequently in HF patients, particularly those with HF-REF, than the rhythm-control strategy. CV hospitalizations occurred more frequently in patients with HF than those without (41.8% vs 17.5%; P < 0.001) and more frequently in patients with HF-REF than in those with HF-PEF (51.6% vs 35.6%; P < 0.0001).

CONCLUSIONS

AF patients with HF, particularly HF-REF, experience heavy symptom and hospitalization burdens, and have relatively low rates of AF control. Further studies are needed to identify ways to improve the management and treatment outcomes of this very high-risk patient population.

Potential role of oral anticoagulants in the treatment of patients with coronary artery disease: focus on dabigatran

The pharmacologic management of patients with high-risk coronary artery disease consists of aspirin and a P2Y12 receptor inhibitor. Chronic oral anticoagulation with warfarin is the major treatment strategy to attenuate thromboembolism or stroke in patients with deep vein thrombosis, pulmonary embolism, heart failure and atrial fibrillation. A substantial percentage of the latter group of patients have coronary artery disease and may require stenting with long-term dual antiplatelet therapy in addition to therapy with warfarin to reduce arterial ischemic events in addition to stroke. These new oral anticoagulants have been developed for long-term therapy to overcome the limitations of warfarin. Dabigatran is a direct thrombin inhibitor and its role in patients with acute coronary syndrome is being explored.

Thrombocytopenia in patients with atrial fibrillation on oral anticoagulation undergoing percutaneous coronary intervention

Thrombocytopenia is often regarded as a risk factor for bleeding complications in patients undergoing percutaneous coronary intervention (PCI). The risk of mild to moderate baseline and acquired thrombocytopenia on bleeding and thrombotic or thromboembolic complications in patients with atrial fibrillation on oral anticoagulation therapy undergoing PCI, however, remains largely unknown. Management of Patients With Atrial Fibrillation undergoing Coronary Artery Stenting is a multicenter European prospective registry enrolling patients with atrial fibrillation undergoing PCI. We assessed the rate of bleeding complications as defined by Bleeding Academic Research Consortium and a composite of major adverse cardiac and cerebrovascular events (MACCE) including all-cause mortality, myocardial infarction, transient ischemic attack or stroke, stent thrombosis, systemic arterial embolism, or revascularization; and a composite of any harmful event (Bleeding Academic Research Consortium and MACCE) at 12-month follow-up in 861 consecutive patients undergoing PCI. Patients were divided into those with mild to moderate baseline thrombocytopenia (platelet count <150 × 10⁹/L; n = 99) and control group (platelet count >150 × 10⁹/L; n = 762). At hospital discharge, thrombocytopenia had no effect on prescribed antithrombotic treatment, and triple therapy (vitamin K antagonist + aspirin + clopidogrel) was the most common combination in both patient groups (69% vs 73%, p = 0.40). No differences in all-cause mortality (12% vs 11%, p = 0.79), MACCE (23% vs 22%, p = 0.87), or bleeding complications (23% vs 19%, p = 0.26) were detected. Acquired in-hospital thrombocytopenia occurred in 9.7% of patients, and it was associated with similar risk of adverse outcomes compared with control group. In conclusion, mild to moderate baseline thrombocytopenia does not seem to have a clinically significant effect on bleeding or thrombotic or thromboembolic complications after PCI in these frail patients receiving multiple antithrombotic drugs.

Triple antithrombotic therapy is the independent predictor for the occurrence of major bleeding complications: analysis of percent time in therapeutic range

BACKGROUND

Triple antithrombotic therapy increases the risk of bleeding events in patients undergoing percutaneous coronary intervention. However, it remains unclear whether good control of percent time in therapeutic range is associated with reduced occurrence of bleeding complications in patients undergoing triple antithrombotic therapy.

METHODS AND RESULTS

This study included 2648 patients (70 ± 11 years; 2037 men) who underwent percutaneous coronary intervention with stent in the Ibaraki Cardiovascular Assessment Study registry and received dual antiplatelet therapy with or without warfarin. Clinical end points were defined as the occurrence of major bleeding complications (MBC), major adverse cardiac and cerebrovascular event, and all-cause death. Among these 2648 patients, 182 (7%) patients received warfarin. After a median follow-up period of 25 months (interquartile range, 15-35 months), MBC had occurred in 48 (2%) patients, major adverse cardiac and cerebrovascular event in 484 (18%) patients, and all-cause death in 206 (8%) patients. Multivariable Cox regression analysis revealed that triple antithrombotic therapy was the independent predictor for the occurrence of MBC (hazard ratio, 7.25; 95% confidence interval, 3.05-17.21; P<0.001). The time in therapeutic range value did not differ between the patients with and without MBC occurrence (83% [interquartile range, 50%-90%] versus 75% [interquartile range, 58%-87%]; P=0.7). However, the mean international normalized ratio of prothrombin time at the time of MBC occurrence was 3.3 ± 2.1. Triple antithrombotic therapy did not have a predictive value for the occurrence of all-cause death (P=0.1) and stroke (P=0.2).

CONCLUSIONS

Triple antithrombotic therapy predisposes patients to an increased risk of MBC regardless of the time in therapeutic range.

Clinical strategies for selecting oral anticoagulants in patients with atrial fibrillation

Atrial fibrillation is a common arrhythmia. One of the important aspects of the management of atrial fibrillation is stroke prevention. Warfarin has been the longstanding anticoagulant used for stroke prevention in patients with atrial fibrillation. There are now three novel oral anticoagulants, which have been studied in randomized controlled trials and subsequently approved by the Federal Drug Administration for stroke prevention in patients with atrial fibrillation. Special patient populations, including renal insufficiency, elderly, prior stroke, and extreme body weights, were represented to varying degrees in the clinical trials of the novel oral anticoagulants. Furthermore, there is variation in the pharmacokinetics and pharmacodynamics of each anticoagulant, which affect the patient populations differently. Patients and clinicians are faced with the task of selecting among the available anticoagulants, and this review is designed to be a tool for clinical decision-making.

Triple oral antithrombotic therapy in atrial fibrillation and coronary artery stenting

Patients with atrial fibrillation affected by an acute coronary syndrome have indications for oral anticoagulation and dual antiplatelet therapy with aspirin and a P2Y12 adenosine diphosphate receptor inhibitor after coronary artery stenting. The concurrent use of all 3 agents, termed triple oral antithrombotic therapy, significantly increases the risk of bleeding. To date, there is a lack of evidence on the proper combination and duration of anticoagulant and antiplatelet agents in patients with indications for both therapies. As such, care has been guided by expert opinion, and there is wide variation in clinician practice. In this review, the latest evidence on the risks and benefits of triple oral antithrombotic therapy in patients with atrial fibrillation after coronary artery stenting is summarized. We discuss the clinical risk scores useful in guiding the prediction of stroke, bleeding, and stent thrombosis. Additionally, we highlight where additional evidence is needed to determine the proper balance of anticoagulant and antiplatelet agents in this patient population.