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Rowland B, Batty JA, Mehran R, Kunadian V. Triple Antiplatelet Therapy and Combinations with Oral Anticoagulants after Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Bai L, Yang XH, Zhou YQ, Cui XR, Fu LZ, Zhang JD. Safety and Efficacy Evaluation of Antithrombotic Therapy with Rivaroxaban and Clopidogrel After PCI in Chinese Patients. Clin Appl Thromb Hemost 2022; 28:10760296221074681. [PMID: 35200040 PMCID: PMC8883290 DOI: 10.1177/10760296221074681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the efficacy and safety of the antithrombotic therapy using the oral anticoagulant rivaroxaban and clopidogrel in Chinese patients with acute coronary syndrome complicated with atrial fibrillation after percutaneous coronary intervention. Methods A total of 100 patients were selected. Patients were randomly divided into two groups: the treatment group (rivaroxaban group) received a therapy of rivaroxaban and clopidogrel. The control group (warfarin group) receivied a combined treatment of warfarin, clopidogrel, and aspirin. The primary outcome endpoint was evaluated based on the adverse cardiac and cerebrovascular events within 12 months. Results A total of 8 (8.00%) main adverse cardiac and cerebrovascular events occurred during the 12 months of follow-up, including 5 (9.80%) in the warfarin group and 3 (6.10%) in the rivaroxaban group. The risk of having main adverse cardiac and cerebrovascular events in the two groups was comparable (P = 0.479). A total of 9 patients (9.00%) were found to have bleeding events, among which 8 patients (15.7%) were in the warfarin group, whereas only 1 patient (2.00%) was in the rivaroxaban group. Therefore, the risk of bleeding in the warfarin group was significantly higher than that in the rivaroxaban group (P = 0.047). Conclusions In Chinese patients with acute coronary syndrome complicated with atrial fibrillation, the efficacy of the dual therapy of oral anticoagulant rivaroxaban plus clopidogrel after percutaneous coronary intervention was similar to that of the traditional triple therapy combined with warfarin, aspirin and clopidogrel, but it has a better safety property, which has potential to widely apply to antithrombotic therapy after PCI
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Affiliation(s)
- Long Bai
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiao-Hong Yang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ya-Qing Zhou
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiao-Ran Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ling-Zhi Fu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ji-Dong Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Zhao S, Hong X, Cai H, Liu M, Li B, Ma P. Antithrombotic Management for Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention or With Acute Coronary Syndrome: An Evidence-Based Update. Front Cardiovasc Med 2021; 8:660986. [PMID: 34262952 PMCID: PMC8273244 DOI: 10.3389/fcvm.2021.660986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/27/2021] [Indexed: 12/13/2022] Open
Abstract
Combined antithrombotic regimens for atrial fibrillation (AF) patients with coronary artery disease, particularly for those who have acute coronary syndrome (ACS) and/or are undergoing percutaneous coronary intervention (PCI), presents a great challenge in the real-world clinical scenario. Conventionally, a triple antithrombotic therapy (TAT), which consists of combined oral anticoagulant therapy to prevent systemic embolism or stroke along with dual antiplatelet therapy to prevent coronary arterial thrombosis (CAT), is used. However, TAT has been associated with a significantly increased risk of bleeding. With the emergence of non-vitamin K antagonist oral anticoagulants (NOACs), randomized controlled trials have demonstrated a better risk-to-benefit ratio of dual antithrombotic therapy (DAT) in combination of a NOAC and with a P2Y12 inhibitor than vitamin K antagonist-based TAT. The results of these studies have impacted the recommendations of current international guidelines, which favor a DAT with a NOAC and P2Y12 inhibitor (especially clopidogrel) in this clinical setting. Additionally, aspirin can be administered during the periprocedural period, while the treatment duration of TAT should be as short as possible. In this article, we summarize the up-to-date evidence regarding antithrombotic regimens for AF patients with PCI or ACS, with a specific focus on the optimal approach and critical discussions of key scientific data and future developments for antithrombotic management in these patients.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Xuejiao Hong
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Haixia Cai
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Mingzhou Liu
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Bing Li
- Department of General Practice, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Peizhi Ma
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
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Uziębło-Życzkowska B, Krzesiński P, Maciorowska M, Gorczyca I, Jelonek O, Wójcik M, Błaszczyk R, Kapłon-Cieślicka A, Gawałko M, Tokarek T, Rajtar-Salwa R, Bil J, Wojewódzki M, Szpotowicz A, Krzciuk M, Bednarski J, Bakuła-Ostalska E, Tomaszuk-Kazberuk A, Szyszkowska A, Wełnicki M, Mamcarz A, Wożakowska-Kapłon B. Antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention, including compliance with current guidelines-data from the POLish Atrial Fibrillation (POL-AF) Registry. Cardiovasc Diagn Ther 2021; 11:14-27. [PMID: 33708474 PMCID: PMC7944221 DOI: 10.21037/cdt-20-839] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 11/16/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although triple antithrombotic therapy (TAT) is recommended in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), guidelines allow an option of dual antithrombotic therapy (DAT). This study assesses the everyday practice of 10 cardiology departments in antithrombotic therapy in AF patients undergoing PCI and its agreement with current guidelines. METHODS This analysis included medical data of AF patients enrolled in the prospective, observational registry (The POLish Atrial Fibrillation-POL-AF) that underwent PCI [elective or due to acute coronary syndrome (ACS)]. RESULTS Of the 3,999 consecutive subjects included, a final analysis was performed on 359 patients that underwent PCI: 148 with urgent PCI due to ACSand 211 patients with elective PCI. Eighty patients in the ACS-group and 120 patients in the elective-PCI group were treated with TAT, although guidelines also allowed DAT. Of 316 patients treated with oral anticoagulants as a part of combination therapy, 275 were on non-vitamin K antagonist oral anticoagulant (NOAC). Reduced doses of NOAC were used in 74 patients treated with rivaroxaban, 60 patients with dabigatran, and 54 patients with apixaban. The proportion of patients treated with reduced NOAC doses adequately to the guidelines was 29%, 100%, and 33% for rivaroxaban, dabigatran, and apixaban, respectively. Inappropriate low doses of NOACs were used in 71% of subjects on rivaroxaban and 67% on apixaban. CONCLUSIONS In patients with AF undergoing PCI, NOACs are definitely preferred over vitamin-K antagonists (VKAs) in TAT/DAT, and an aggressive antithrombotic strategy with TAT is frequently chosen even if DAT is permissible by the guidelines. Label adherence of using reduced NOAC dose during combination therapy is not satisfactory for apixaban and rivaroxaban and probably results from too cautious an approach to the known indications for reduced therapy. The study is registered in the database Clinical Trials-NCT04419012.
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Affiliation(s)
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Małgorzata Maciorowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Iwona Gorczyca
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
- Collegium Medicum, The Jan Kochanowski University, Kielce, Poland
| | - Olga Jelonek
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
- Collegium Medicum, The Jan Kochanowski University, Kielce, Poland
| | - Maciej Wójcik
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | | | - Monika Gawałko
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Tokarek
- Department of Cardiology and Cardiovascular Interventions, University Hospital, Krakow, Poland
| | - Renata Rajtar-Salwa
- Department of Cardiology and Cardiovascular Interventions, University Hospital, Krakow, Poland
| | - Jacek Bil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Michał Wojewódzki
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Anna Szpotowicz
- Department of Cardiology, Regional Hospital, Ostrowiec Świętokrzyski, Poland
| | - Małgorzata Krzciuk
- Department of Cardiology, Regional Hospital, Ostrowiec Świętokrzyski, Poland
| | - Janusz Bednarski
- Department of Cardiology, St John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
| | | | | | - Anna Szyszkowska
- Department of Cardiology, University Hospital of Bialystok, Białystok, Poland
| | - Marcin Wełnicki
- 3rd Department of Internal Diseases and Cardiology, Warsaw Medical University, Warsaw, Poland
| | - Artur Mamcarz
- 3rd Department of Internal Diseases and Cardiology, Warsaw Medical University, Warsaw, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
- Collegium Medicum, The Jan Kochanowski University, Kielce, Poland
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Lopes RD, Hong H, Harskamp RE, Bhatt DL, Mehran R, Cannon CP, Granger CB, Verheugt FWA, Li J, ten Berg JM, Sarafoff N, Gibson CM, Alexander JH. Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Network Meta-analysis of Randomized Controlled Trials. JAMA Cardiol 2019; 4:747-755. [PMID: 31215979 PMCID: PMC6584885 DOI: 10.1001/jamacardio.2019.1880] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/02/2019] [Indexed: 12/22/2022]
Abstract
Importance The antithrombotic treatment of patients with atrial fibrillation (AF) and coronary artery disease, in particular with acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI), poses a significant treatment dilemma in clinical practice. Objective To study the safety and efficacy of different antithrombotic regimens using a network meta-analysis of randomized controlled trials in this population. Data Sources PubMed, EMBASE, EBSCO, and Cochrane databases were searched to identify randomized controlled trials comparing antithrombotic regimens. Study Selection Four randomized studies were included (n = 10 026; WOEST, PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS). Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review and network meta-analysis between 4 regimens using a Bayesian random-effects model. A pre hoc statistical analysis plan was written, and the review protocol was registered at PROSPERO. Data were analyzed between November 2018 and February 2019. Main Outcomes and Measures The primary safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding; secondary safety outcomes were combined TIMI major and minor bleeding, trial-defined primary bleeding events, intracranial hemorrhage, and hospitalization. The primary efficacy outcome was trial-defined major adverse cardiovascular events (MACE); secondary efficacy outcomes were individual components of MACE. Results The overall prevalence of ACS varied from 28% to 61%. The mean age ranged from 70 to 72 years; 20% to 29% of the trial population were women; and most patients were at high risk for thromboembolic and bleeding events. Compared with a regimen of vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT; P2Y12 inhibitor plus aspirin), the odds ratios (ORs) for TIMI major bleeding were 0.58 (95% CI, 0.31-1.08) for VKA plus P2Y12 inhibitor, 0.49 (95% CI, 0.30-0.82) for non-VKA oral anticoagulant (NOAC) plus P2Y12 inhibitor, and 0.70 (95% CI, 0.38-1.23) for NOAC plus DAPT. Compared with VKA plus DAPT, the ORs for MACE were 0.96 (95% CI, 0.60-1.46) for VKA plus P2Y12 inhibitor, 1.02 (95% CI, 0.71-1.47) for NOAC plus P2Y12 inhibitor, and 0.94 (95% CI, 0.60-1.45) for NOAC plus DAPT. Conclusions and Relevance A regimen of NOACs plus P2Y12 inhibitor was associated with less bleeding compared with VKAs plus DAPT. Strategies omitting aspirin caused less bleeding, including intracranial bleeding, without significant difference in MACE, compared with strategies including aspirin. Our results support the use of NOAC plus P2Y12 inhibitor as the preferred regimen post-percutaneous coronary intervention for these high-risk patients with AF. A regimen of VKA plus DAPT should generally be avoided.
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Affiliation(s)
- Renato D. Lopes
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Hwanhee Hong
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Ralf E. Harskamp
- Amsterdam UMC Universiteit van Amsterdam, Amsterdam Public Health, Academisch Medisch Centrum, Amsterdam, the Netherlands
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massaschusetts
| | | | - Christopher P. Cannon
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massaschusetts
| | | | | | - Jianghao Li
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Jurriën M. ten Berg
- St Antonius Ziekenhuis, Nieuwegein, the Netherlands
- Universitair Medisch Centrum Groningen, Groningen, the Netherlands
| | | | - C. Michael Gibson
- Beth Israel Hospital, Harvard Medical School, Boston, Massaschusetts
| | - John H. Alexander
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
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Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI. J Am Coll Cardiol 2019; 74:83-99. [DOI: 10.1016/j.jacc.2019.05.016] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022]
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Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:3. [DOI: 10.1007/s11936-019-0705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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