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Jung J, Seo Y, Her SH, Lee JH, Lee K, Yoo KD, Moon KW, Moon D, Lee SN, Jang WY, Choi IJ, Lee JH, Lee SR, Lee SW, Yun KH, Lee HJ. Prognostic Impact of Atrial Fibrillation in Patients with Heavily Calcified Coronary Artery Disease Receiving Rotational Atherectomy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1808. [PMID: 37893526 PMCID: PMC10608542 DOI: 10.3390/medicina59101808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/02/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: Although both rotational atherectomy (RA) and atrial fibrillation (AF) have a high thrombotic risk, there have been no previous studies on the prognostic impact of AF in patients who undergo percutaneous coronary intervention (PCI) using RA. Thus, the aim of the present study was to determine the prognostic impact of AF in patients undergoing PCI using RA. Materials and Methods: A total of 540 patients who received PCI using RA were enrolled between January 2010 and October 2019. Patients were divided into AF and sinus rhythm groups according to the presence of AF. The primary endpoint was net adverse clinical events (NACEs) defined as a composite outcome of all-cause death, myocardial infarction, target vessel revascularization, cerebrovascular accident, or total bleeding. Results: Although in-hospital adverse events showed no difference between those with AF and those without AF (in-hospital events, 54 (11.0%) vs. 6 (12.2%), p = 0.791), AF was strongly associated with an increased risk of NACE at 3 years (NACE: hazard ratio, 1.880; 95% confidence interval, 1.096-3.227; p = 0.022). Conclusions: AF in patients who underwent PCI using RA was strongly associated with poor clinical outcomes. Thus, more attention should be paid to thrombotic and bleeding risks.
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Affiliation(s)
- Jin Jung
- Department of Cardiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (J.J.); (K.-D.Y.); (K.-W.M.); (D.M.); (S.-N.L.); (W.-Y.J.)
| | - Yeonjoo Seo
- Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 07345, Republic of Korea;
| | - Sung-Ho Her
- Department of Cardiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (J.J.); (K.-D.Y.); (K.-W.M.); (D.M.); (S.-N.L.); (W.-Y.J.)
| | - Jae-Hwan Lee
- Department of Cardiology in Internal Medicine, Chungnam National University School of Medicine, Chungnam National University Sejong Hospital, Sejong 30099, Republic of Korea
| | - Kyusup Lee
- Department of Cardiology, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 34943, Republic of Korea;
| | - Ki-Dong Yoo
- Department of Cardiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (J.J.); (K.-D.Y.); (K.-W.M.); (D.M.); (S.-N.L.); (W.-Y.J.)
| | - Keon-Woong Moon
- Department of Cardiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (J.J.); (K.-D.Y.); (K.-W.M.); (D.M.); (S.-N.L.); (W.-Y.J.)
| | - Donggyu Moon
- Department of Cardiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (J.J.); (K.-D.Y.); (K.-W.M.); (D.M.); (S.-N.L.); (W.-Y.J.)
| | - Su-Nam Lee
- Department of Cardiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (J.J.); (K.-D.Y.); (K.-W.M.); (D.M.); (S.-N.L.); (W.-Y.J.)
| | - Won-Young Jang
- Department of Cardiology, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 16247, Republic of Korea; (J.J.); (K.-D.Y.); (K.-W.M.); (D.M.); (S.-N.L.); (W.-Y.J.)
| | - Ik-Jun Choi
- Department of Cardiology, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon 21431, Republic of Korea;
| | - Jang-Hoon Lee
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu 41944, Republic of Korea;
| | - Sang-Rok Lee
- Department of Cardiology, Chonbuk National University Hospital, Jeonju 54907, Republic of Korea;
| | - Seung-Whan Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea;
| | - Kyeong-Ho Yun
- Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan 54538, Republic of Korea;
| | - Hyun-Jong Lee
- Department of Internal Medicine, Sejong General Hospital, Bucheon 14754, Republic of Korea;
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Takeda T, Dohke T, Ueno Y, Mastui T, Fujii M, Takayama T, Dochi K, Miyamoto A, Mabuchi H, Wada A. Clinical utility of the BIWACO score for patients with atrial fibrillation after percutaneous coronary intervention. Heart Vessels 2023; 38:96-105. [PMID: 35871206 PMCID: PMC9810676 DOI: 10.1007/s00380-022-02128-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 06/23/2022] [Indexed: 01/07/2023]
Abstract
No predictive clinical risk scores for net adverse clinical events (NACE) have been developed for patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). We evaluated NACE to develop clinically applicable risk-stratification scores in the Bleeding and thrombotic risk evaluation In patients With Atrial fibrillation under COronary intervention (BIWACO) study, a multicenter survey which has enrolled a total of 7837 patients. We also investigated the current status and time trends for the use of antithrombotic drugs. A total of 188 AF patients who had received PCI were examined. At discharge, 65% of patients were prescribed a triple therapy (TT), 6% were prescribed a dual therapy, the remaining 29% of patients received dual-antiplatelet therapy. After 4 years, the fraction of patients continuing TT decreased by 15%, whereas oral anticoagulant alone was only 2% of patients. NACE developed in 20% of patients, resulting in death in 5% of the patients, and the remaining 13% experienced bleeding events. We developed risk scores for NACE comprising the five strongest predictive items, which we designated BIWACO scores. The area under the curve was 0.774 for NACE. Our study explored the differences in treatment practices and guideline recommendations for antithrombotic therapy. We concluded that our BIWACO score is useful for predicting clinical outcomes in AF-patients after PCI.
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Affiliation(s)
- Teruki Takeda
- grid.513109.fDivision of Cardiology, Koto Memorial Hospital, Higashiomi-shi, Japan
| | - Tomohiro Dohke
- Division of Cardiology, Kohka Public Hospital, Koka-shi, Japan
| | - Yoshiki Ueno
- Division of Cardiology, Nagahama Red Cross Hospital, Nagahama-shi, Japan
| | - Toshiki Mastui
- Division of Cardiology, Shiga Hospital JCHO, Otsu-shi, Japan
| | - Masanori Fujii
- Department of Cardiology, Omi Medical Center, 1660 Yabase, Kusatsu-shi, Shiga 525-8585 Japan
| | | | - Kenichi Dochi
- Division of Cardiology, Nagahama Red Cross Hospital, Nagahama-shi, Japan
| | - Akashi Miyamoto
- Division of Cardiology, Shiga Hospital JCHO, Otsu-shi, Japan
| | - Hiroshi Mabuchi
- grid.513109.fDivision of Cardiology, Koto Memorial Hospital, Higashiomi-shi, Japan
| | - Atsuyuki Wada
- Department of Cardiology, Omi Medical Center, 1660 Yabase, Kusatsu-shi, Shiga 525-8585 Japan
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Chueh HH, Huang ST, Chang SH, Lin SY, Hsiao FY. Comparative effectiveness and safety of different combinations of antithrombotic regimens in atrial fibrillation patients with stent insertions. Clin Pharmacol Ther 2022; 112:864-872. [PMID: 35680555 DOI: 10.1002/cpt.2684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/28/2022] [Indexed: 11/10/2022]
Abstract
This study aims to compare the risks of major adverse cardiac events (MACEs), including cardiovascular death, myocardial infarction, ischemic stroke and transient ischemic attack, and major bleeding across different antithrombotic regimens in Asian atrial fibrillation (AF) patients with stent insertions. We conducted a retrospective cohort study using Taiwan's National Health Insurance Research Database and National Mortality Registry. A total of 10,208 nonvalvular AF patients who had undergone percutaneous coronary intervention (PCI) with stents for the first time in 2007-2017 were identified. Most patients (68.4%) were prescribed dual antiplatelet therapy (DAPT) at discharge. During follow-up, the use of anticoagulants increased, and double therapy (an antiplatelet plus an anticoagulant) was the most frequently prescribed therapy. The risks of MACEs were comparable in double therapy and had a similar risk of MACEs compared to DAPT (aHR 0.86; 95% CI 0.67-1.11). Triple therapy (DAPT plus an anticoagulant) also had similar effectiveness to double therapy (1.23; 0.84-1.80) or DAPT (1.06; 0.77-1.45). However, triple therapy was associated with a nearly twofold higher major bleeding risk than DAPT and double therapy (1.97; 1.31-2.94 and 1.80; 1.10-2.95, respectively). DAPT was the most frequently prescribed antithrombotic regimen at discharge for Asian AF patients who had undergone stent insertions. DAPT and double and triple therapy had comparable effectiveness, but triple therapy had a significantly higher major bleeding risk than either DAPT or double therapy.
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Affiliation(s)
- Han-Hsin Chueh
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Shih-Tsung Huang
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan
| | - Shang-Hung Chang
- Department of Cardiology, Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Medicine, Chang Gung University, Linkou, Taiwan
| | - Shin-Yi Lin
- School of Pharmacy, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, National Taiwan University, Taipei, Taiwan.,School of Pharmacy, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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Cho MS, Kang DY, Oh YS, Lee CH, Choi EK, Lee JH, Kwon CH, Park GM, Park HW, Park KH, Park KM, Hwang J, Yoo KD, Cho YR, Kim YR, Hwang KW, Jin ES, Kim PJ, Kim KH, Park DW, Nam GB. Edoxaban-based long-term antithrombotic therapy in patients with atrial fibrillation and stable coronary disease: Rationale and design of the randomized EPIC-CAD trial. Am Heart J 2022; 247:123-131. [PMID: 35149036 DOI: 10.1016/j.ahj.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/26/2022] [Accepted: 01/29/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anticoagulants are the standard therapy for patients with atrial fibrillation (AF) and antiplatelet therapy for those with coronary artery disease (CAD). However, compelling clinical evidence is still lacking regarding the long-term maintenance strategy with the combination of anticoagulant and antiplatelet drugs in patients with AF and stable CAD. DESIGN The EPIC-CAD trial is an investigator-initiated, multicenter, open-label randomized trial comparing the safety and efficacy of 2 antithrombotic strategies in patients with high-risk AF (CHA2DS2-VASc score ≥ 2 points) and stable CAD (≥6 months after revascularization for stable angina or ≥12 months for acute coronary syndrome; or medical therapy alone). Patients (approximately N = 1,038) will be randomly assigned at a 1:1 ratio to (1) monotherapy with edoxaban (a non-vitamin K antagonist oral anticoagulant) or (2) combination therapy with edoxaban plus a single antiplatelet agent. The primary endpoint is the net composite outcome of death from any cause, stroke, systemic embolism, myocardial infarction, unplanned revascularization, and major or clinically relevant nonmajor bleeding at 1 year after randomization. RESULTS As of December 2021, approximately 901 patients had been randomly enrolled over 2 years at 18 major cardiac centers across South Korea. The completed enrollment is expected at the mid-term of 2022, and the primary results will be available by 2023. CONCLUSIONS EPIC-CAD is a large-scale, multicenter, pragmatic design trial, which will provide valuable clinical insight into edoxaban-based long-term antithrombotic therapy in patients with high-risk AF and stable CAD.
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Batchelor RJ, Dinh D, Noaman S, Brennan A, Clark D, Ajani A, Freeman M, Stub D, Reid CM, Oqueli E, Yip T, Shaw J, Walton A, Duffy SJ, Chan W. Adverse 30-Day Clinical Outcomes and Long-Term Mortality Among Patients With Preprocedural Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Heart Lung Circ 2022; 31:638-646. [PMID: 35125322 DOI: 10.1016/j.hlc.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 11/16/2021] [Accepted: 12/09/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined. METHODS We analysed data from the multicentre Melbourne Interventional Group Registry from 2014-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index. RESULTS 13,286 procedures were included, with 800 (6.0%) patients in AF and 12,486 (94.0%) in SR. Compared to SR, patients with AF were older (72.9±10.9 vs 64.1±12.0 p<0.001) and more likely to have comorbidities including diabetes mellitus (31.3% vs 25.0% p<0.001), hypertension (74.4% vs 65.1% p<0.001) and moderate to severe left ventricular systolic dysfunction (36.6% vs 19.5% p<0.001). Atrial fibrillation was associated with an increased risk of in-hospital mortality (11.0% vs 2.5% p<0.001) and MACE (composite of all-cause mortality, myocardial infarction, or target vessel revascularisation) (11.9% vs 4.2% p<0.001). In-hospital major bleeding was more common in the AF group (3.1% vs 1.0% p<0.001). On Cox proportional hazards modelling, AF was an independent predictor of long-term mortality (adjusted HR 1.38 95% CI 1.11-1.72 p<0.004) at a mean follow-up of 2.3±1.5 years. CONCLUSIONS Preprocedural AF is common among patients presenting for PCI. Preprocedural AF is associated with high-rates of comorbid illnesses and portends higher risk of short- and long-term outcomes including mortality underscoring the need for careful evaluation of its risks prior to PCI.
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Affiliation(s)
- Riley J Batchelor
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Diem Dinh
- Monash University, Melbourne, Vic, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | | | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - Christopher M Reid
- Monash University, Melbourne, Vic, Australia; Curtin University, Perth, WA, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Vic, Australia
| | - Thomas Yip
- Deakin University, Geelong, Vic, Australia; Department of Cardiology, Barwon Health, Geelong, Vic, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia.
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Kwon O, Park DW. Antithrombotic Therapy After Acute Coronary Syndromes or Percutaneous Coronary Interventions in East Asian Populations. JACC. ASIA 2022; 2:1-18. [PMID: 36340250 PMCID: PMC9627845 DOI: 10.1016/j.jacasi.2021.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/13/2021] [Accepted: 12/03/2021] [Indexed: 05/01/2023]
Abstract
Because guidelines and recommendations in response to multiple randomized clinical trials (RCTs) of new therapies undergo rapid changes, antithrombotic therapies for patients after acute coronary syndrome, or percutaneous coronary intervention, are becoming more complex in daily clinical practice. The proportion of Asian populations enrolled in landmark RCTs is substantially low, which limits the direct application of trial findings into clinical practice in Asian countries. Moreover, compared with Caucasian patients, East Asian patients are considered to have a different ischemia/bleeding propensity in response to antithrombotic therapy, known as the "East Asian paradox" (ie, more bleeding events but fewer thromboembolic events). Coincident with consecutive RCTs in Western populations to optimize antithrombotic strategies, several such studies have now been conducted in East Asian cohorts. Herein, we provide a comprehensive summary of the key RCTs in this regard and propose future directions and perspectives for optimal antithrombotic therapies in East Asian patients.
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Key Words
- ACS, acute coronary syndrome
- BARC, Bleeding Academic Research Consortium
- CAD, coronary artery disease
- CHIP, complex higher-risk and indicated procedure/patients
- DAPT, dual antiplatelet therapy
- DES, drug-eluting stent
- DOAC, direct oral anticoagulant
- HBR, high bleeding risk
- MI, myocardial infarction
- OAC, oral anticoagulation
- PCI, percutaneous coronary intervention
- PRU, P2Y12 reaction unit
- RCT, randomized controlled trial
- acute coronary syndrome
- antiplatelets
- antithrombotic therapy
- percutaneous coronary intervention
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Affiliation(s)
- Osung Kwon
- Division of Cardiology, Department of Internal Medicine, The Catholic University of Korea, Eunpyeong St Mary's Hospital, Seoul, South Korea
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Duk-Woo Park
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- Address for correspondence: Dr Duk-Woo Park, Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, South Korea.
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Hamaguchi T, Iwanaga Y, Nakai M, Morita Y, Inoko M. Clinical Significance of Atrial Fibrillation Status in Patients With Percutaneous Coronary Intervention. CJC Open 2021; 3:1357-1364. [PMID: 34901804 PMCID: PMC8640652 DOI: 10.1016/j.cjco.2021.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/30/2021] [Indexed: 01/21/2023] Open
Abstract
Background Patients undergoing percutaneous coronary intervention (PCI) often develop atrial fibrillation (AF). We investigated the clinical effects of AF status on in-hospital mortality and complications in patients with PCI using a recent large-scale nationwide dataset. Methods Using a claims-based dataset from 1022 hospitals in Japan for the time period between 2012 and 2016, patients with PCI were identified and classified into 3 groups according to AF status: no AF, prevalent AF before admission, and incident AF after admission. In-hospital mortality, complications, and medical costs were compared in crude and propensity-matched cohorts. Results In 659,525 hospitalized patients undergoing PCI, prevalent AF and incident AF were observed in 6.0% and 1.3% patients, respectively; the AF rates increased over 5 years. A greater proportion of older patients and patients with comorbidities had both of these categories of AF; undergoing PCI for acute coronary syndrome was common in incident AF. Both prevalent AF and incident AF were associated with worse crude outcomes and complications during hospitalization. In propensity-matched cohorts, incident AF was associated with a higher in-hospital mortality rate, longer length of stay, higher direct costs, and higher rate of complications, including stroke and acute kidney injury, compared with prevalent AF. These outcomes, except length of in-hospital stay, did not change for either AF status over 5 years. Conclusions Prevalent AF and incident AF in patients undergoing PCI were both associated with deteriorating crude outcomes and complications; in particular, incident AF was associated with worse adjusted outcomes and complications. Further efforts are needed to improve patient outcomes in an aging society in which the incidence of AF is increasing.
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Affiliation(s)
- Toka Hamaguchi
- Cardiovascular Center, Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yusuke Morita
- Cardiovascular Center, Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Moriaki Inoko
- Cardiovascular Center, Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Osaka, Japan
- Corresponding author: Dr Moriaki Inoko, Cardiovascular Center, Tazuke Kofukai Foundation, Medical Research Institute, Kitano Hospital, Osaka, Japan.
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Benetou DR, Vlachakis PK, Varlamos C, Alexopoulos D. Antithrombotic Therapy in Complex Percutaneous Coronary Intervention Patients Requiring Chronic Anticoagulation. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The optimal antithrombotic treatment in patients receiving oral anticoagulation undergoing percutaneous coronary intervention (PCI) has been a field of intensive research. Although triple antithrombotic therapy had been, until lately, the strategy of choice, recent evidence points to the superiority of dual antithrombotic therapy regarding bleeding prevention, without significantly compromising efficacy. In the further challenging scenario of complex PCI, associated with a higher ischemic risk, the efficacy of an aspirin-free strategy, adopted shortly after the index event is under question, rendering decision-making a fairly difficult scenario for clinicians. Since patients with an indication for oral anticoagulation undergoing complex PCI are underrepresented in randomized trials, there are scarce data regarding the optimal treatment strategy in such patients. This review aims to analyze and compare different approaches regarding the type and duration of antithrombotic regimens, focusing on both safety and efficacy outcomes, as well as to discuss recent guidelines’ suggestions regarding the therapeutic approach in patients receiving oral anticoagulation undergoing PCI procedures of increased complexity.
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Affiliation(s)
- Despoina-Rafailia Benetou
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Panayotis K Vlachakis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Charalampos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Park J, Jung JH, Choi EK, Lee SW, Kwon S, Lee SR, Kang J, Han KD, Park KW, Oh S, Lip GYH. Longitudinal Patterns in Antithrombotic Therapy in Patients with Atrial Fibrillation after Percutaneous Coronary Intervention in the Non-Vitamin K Oral Anticoagulant Era: A Nationwide Population-Based Study. J Clin Med 2021; 10:jcm10071505. [PMID: 33916604 PMCID: PMC8038511 DOI: 10.3390/jcm10071505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/25/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022] Open
Abstract
We investigated whether longitudinal patterns in antithrombotic therapy have changed after the introduction of non-vitamin K oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI). Using a claims database of the Korean AF population who underwent PCI between 2012 and 2016 (n = 18,691), we analyzed prescription records of oral anticoagulants (OACs) and antiplatelets at 3-month intervals over 2 years after PCI. The study population was stratified (pre-NOAC, transition, and NOAC era) using time-periods of NOAC introduction in Korea and an expansion of reimbursement for NOAC in AF as indicators. The overall rates of OAC were low at baseline (24.9%, 26.9%, and 35.2% in pre-NOAC, transition, and NOAC era, respectively), contrary to high rates of dual antiplatelet therapy (DAPT) (73.3%, 71.4%, and 63.6%). However, OAC prescription rates were increased at 1-year (18.5%, 22.5%, and 31.6%), and 2-year follow-up (17.8%, 24.2%, and 31.8%) from pre-NOAC to NOAC era. In NOAC era, 63.5% of baseline OAC prescriptions comprised NOAC, of which 96.4% included triple therapy with DAPT. Over 2 years, we observed increasing rates of double therapy with a single antiplatelet (18.3% and 20.0% at 1- and 2-year follow-up) and OAC monotherapy (2.7% and 8.9% at 1- and 2-year follow-up).
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Affiliation(s)
- Jiesuck Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Jin-Hyung Jung
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-H.J.); (K.-D.H.)
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
- Correspondence: ; Tel.: +82-2-2072-0688; Fax: +82-2-762-9662
| | - Seung-Woo Lee
- Department of Statistics and Actuarial Science, Soongsil University, Seoul 06978, Korea;
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Kyung-Do Han
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-H.J.); (K.-D.H.)
| | - Kyung-Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul 03080, Korea; (J.P.); (S.K.); (S.-R.L.); (J.K.); (K.-W.P.); (S.O.)
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
| | - Gregory Y. H. Lip
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul 03080, Korea;
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Chest & Heart Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
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10
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Kim SS, Kim HK. Beginning the Journey to Find Optimal Antithrombotic Regimens for Korean Patients with Atrial Fibrillation after Percutaneous Coronary Intervention. Korean Circ J 2021; 51:423-425. [PMID: 33764014 PMCID: PMC8112185 DOI: 10.4070/kcj.2021.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/29/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Sung Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea.
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11
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Kwon S, Jung JH, Choi EK, Lee SW, Park J, Lee SR, Kang J, Han K, Park KW, Oh S, Lip GYH. Impact of Non-Vitamin K Antagonist Oral Anticoagulants on the Change of Antithrombotic Regimens in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Korean Circ J 2021; 51:409-422. [PMID: 33764010 PMCID: PMC8112178 DOI: 10.4070/kcj.2020.0407] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/30/2020] [Accepted: 12/16/2020] [Indexed: 12/12/2022] Open
Abstract
Background and Objectives Antithrombotic therapy after percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) has changed in recent years with new data from large randomized trials and updates to clinical guidelines. This study aimed to investigate the trends in periprocedural antithrombotic regimens in Korean patients with AF undergoing PCI with non-vitamin K antagonist oral anticoagulants (NOACs). Methods Using the claims database of the Health Insurance Review and Assessment during 2013–2018, 27,594 patients with AF undergoing PCI were identified. The annual prevalence of PCI and prescriptions of each antithrombotic agent, including antiplatelet agents and oral anticoagulants, within 30 days after PCI were investigated. Results During 2013–2018, the number of patients with AF undergoing PCI increased up to 1.3-fold (from 3,913 to 5,075 patients per year). After the introduction of NOACs, the proportion of dual antiplatelet therapy (DAPT) decreased from 71.9% to 49.8% but still occupied the largest proportion among antithrombotic regimens. Triple antithrombotic therapy (TAT) use increased from 25.4% to 46.0%, and NOAC has rapidly replaced warfarin as the oral anticoagulant of choice. TAT was preferred to DAPT for patients with CHA2DS2-VASc score ≥2. Among various factors, prior intracranial hemorrhage was the most powerful predictor of favoring DAPT use over TAT. Conclusion Since the introduction of NOACs, the patterns of periprocedural antithrombotic regimens have changed rapidly toward more use of TAT, specifically with NOAC-based regimen. Appropriate stroke prevention with oral anticoagulants is still underutilized in patients with AF undergoing PCI in Korea.
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Affiliation(s)
- Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Hyung Jung
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
| | - Seung Woo Lee
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Jiesuck Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - So Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Gregory Y H Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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12
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Double or Triple Antithrombotic Treatment in Atrial Fibrillation Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Am J Cardiovasc Drugs 2021; 21:11-20. [PMID: 32170515 DOI: 10.1007/s40256-020-00403-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have traditionally received triple antithrombotic therapy (TAT) consisting of aspirin and a P2Y12 inhibitor plus an oral anticoagulant (OAC) to reduce atherothrombotic events, even though this strategy is associated with a high risk of severe bleeding. Recent trials have indicated that dual antithrombotic therapy (DAT), consisting of a P2Y12 inhibitor plus an OAC, may be superior to TAT in terms of bleeding risk; however, the trade-off regarding ischemic complications may be questionable. Patients who have had a myocardial infarction (MI) before undergoing PCI warrant special consideration because of the accompanying high ischemic risk, including stent thrombosis, which might be exacerbated by an aspirin-free strategy such as DAT. In particular, in the acute phase of ST-segment elevation MI (STEMI), the highly prothrombotic milieu may necessitate initial TAT, though durations may vary, making a tailored antithrombotic regimen for this high-risk subset of patients a fairly challenging and difficult scenario for clinicians. Since patients with MI, especially STEMI, are underrepresented in randomized trials, data regarding the optimal antithrombotic treatment in such patients are sparse. This review aims to analyze the outcomes of different antithrombotic regimens in patients with MI and AF undergoing PCI, define the role of DAT versus TAT regarding safety and efficacy outcomes, and address controversial issues and future perspectives.
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13
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Park J, Choi EK, Han KD, Kim B, Choi YJ, Lee SR, Kang J, Cha MJ, Park KW, Oh S, Lip GYH. Outcomes in relation to antithrombotic therapy among patients with atrial fibrillation after percutaneous coronary intervention. PLoS One 2020; 15:e0240161. [PMID: 33057407 PMCID: PMC7561121 DOI: 10.1371/journal.pone.0240161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUNDS We investigated the prognostic impact of antithrombotic regimens at 1-year after percutaneous coronary intervention (PCI) among patients with atrial fibrillation (AF). METHOD AND RESULTS A total of 13,278 AF patients who underwent PCI from 2009 to 2013 were selected from Korean National Health Insurance Service database. Patients were categorized by antithrombotic regimens at 1-year after PCI: (1) OAC with or without single antiplatelet (OAC±SAPT); (2) triple therapy (TT) and (3) antiplatelets (APT) only. After propensity score matching, composite ischaemia (death, myocardial infarction, and stroke), composite bleeding (intracranial hemorrhage and gastrointestinal bleeding), and a composite clinical outcome (composite ischaemia and bleeding) were compared. Of total population, 1,100 (8.3%), 746 (5.6%), and 11,432 (86.1%) were treated with OAC±SAPT, TT, and APT only, respectively. Compared to OAC±SAPT group, the TT group had significantly higher risk of the composite clinical outcome (hazard ratio [HR] 1.46, 95% confidence interval [CI] 1.00-2.13) attributed to a higher trend in both ischaemia (HR 1.63, 95% CI 0.99-2.67) and bleeding (HR 1.22, 95% CI 0.69-2.13). The APT only group showed a higher risk of ischaemia (HR 1.85, 95% CI 1.25-2.74), despite a lower risk of bleeding (HR 0.55, 95% CI 0.32-0.94) compared to OAC±SAPT group. CONCLUSIONS OAC±SAPT was associated with better clinical outcomes compared to TT or APT only treatments, beyond 1-year after PCI among Asians with AF.
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Affiliation(s)
- Jiesuck Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung-Do Han
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - You-Jung Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Myung-Jin Cha
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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14
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Lee JH, Kim SH, Lee W, Cho Y, Kang SH, Park JJ, Oh IY, Yoon CH, Suh JW, Cho YS, Youn TJ, Chae IH, Choi DJ. New-onset paroxysmal atrial fibrillation in acute myocardial infarction: increased risk of stroke. BMJ Open 2020; 10:e039600. [PMID: 32967885 PMCID: PMC7513639 DOI: 10.1136/bmjopen-2020-039600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To investigate the long-term prognostic implications of transient new-onset atrial fibrillation (AF) in patients with acute myocardial infarction (AMI). DESIGN Retrospective observational study. SETTING Single tertiary centre. PARTICIPANTS This study included 2523 patients who presented with AMI from 3 June 2003 to 24 February 2015, after the exclusion of those with prior AF or in-hospital death. OUTCOME MEASURES Patients were divided into three groups according to the occurrence and type of new-onset AF: (1) sinus rhythm (SR) group; (2) paroxysmal AF (PaAF: AF converted to SR prior to discharge) group and (3) persistent AF (PeAF: AF persisted during the hospitalisation) group. Post-discharge all-cause mortality and stroke incidences were compared between the groups. RESULTS New-onset AF was observed in 271 patients (10.7%; PaAF: 230, PeAF: 41). The median follow-up period was 7.2 years (IQR: 5.2-9.4). The incidence of all-cause death and stroke was highest in the PeAF group, followed by the PaAF and SR groups (all-cause mortality: 48.8% vs 26.5% vs 14.7%, p<0.001; stroke 22.0% vs 8.3% vs 4.4%, p<0.001). In the multivariable analysis, PaAF and PeAF were associated with an increased risk of stroke (PaAF, HR: 1.972, 95% CI: 1.162-3.346; PeAF, HR: 5.160, CI: 2.242-11.873) compared with SR. The PaAF group showed a higher incidence of post-discharge AF than the SR group (29.1% vs 4.2%, p<0.001). CONCLUSIONS New-onset AF following AMI is associated with poor long-term outcomes. Even when AF episodes are brief and are converted to SR, new-onset AF remains associated with an increased risk of recurrent AF and stroke.
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Affiliation(s)
- Ji Hyun Lee
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Sun-Hwa Kim
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Wonjae Lee
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Youngjin Cho
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Si-Hyuck Kang
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Jin Joo Park
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Il-Young Oh
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Chang-Hwan Yoon
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Jung-Won Suh
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Young-Seok Cho
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Tae-Jin Youn
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - In-Ho Chae
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
| | - Dong-Ju Choi
- Division of Cardiology and Cardiovascular Center, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, The Republic of Korea
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15
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Limbruno U, De Sensi F, Cresti A, Picchi A, Lena F, De Caterina R. Optimal Antithrombotic Treatment of Patients with Atrial Fibrillation Early after an Acute Coronary Syndrome-Triple Therapy, Dual Antithrombotic Therapy with an Anticoagulant… Or, Rather, Temporary Dual Antiplatelet Therapy? J Clin Med 2020; 9:jcm9082673. [PMID: 32824861 PMCID: PMC7464261 DOI: 10.3390/jcm9082673] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/09/2020] [Accepted: 08/12/2020] [Indexed: 12/20/2022] Open
Abstract
The combination of atrial fibrillation (AF) and acute coronary syndrome (ACS) is a complex situation in which a three-dimensional risk-cardioembolic, coronary, and hemorrhagic-has to be carefully managed. Triple antithrombotic therapy (TAT) is burdened with a high risk of serious bleeding, while dual antithrombotic therapy with an anticoagulant (DAT) likely provides only suboptimal coronary protection early after stent implantation. Moreover, TAT precludes the advantages provided by the use of the latest and more potent P2Y12 inhibitors in ACS patients. Here, we aimed to simulate and compare the expected coronary, cardioembolic, and hemorrhagic outcomes offered by DAT, TAT, or modern dual antiplatelet therapy (DAPT) with aspirin plus one of the latest P2Y12 inhibitors in AF patients early after an ACS. The comparison of numbers needed to treat to prevent major adverse events with the various antithrombotic regimens suggests that AF-ACS patients at high ischemic and hemorrhagic risk and at moderately low embolic risk (CHA2DS2VASc score 2-4) might safely withhold anticoagulation after revascularization for one month taking advantage of a modern DAPT, with a favorable risk-to-benefit ratio. In conclusion, this strategy, not sufficiently addressed in recent European and North American guidelines or consensus documents, adds to the spectrum of treatment options in these difficult patients; it might be the best choice in a substantial number of patients; and should be prospectively tested in a randomized controlled trial.
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Affiliation(s)
- Ugo Limbruno
- Cardioneurovascular Department, Azienda USL Toscana Sudest, 58100 Grosseto, Italy; (U.L.); (F.D.S.); (A.C.); (A.P.)
| | - Francesco De Sensi
- Cardioneurovascular Department, Azienda USL Toscana Sudest, 58100 Grosseto, Italy; (U.L.); (F.D.S.); (A.C.); (A.P.)
| | - Alberto Cresti
- Cardioneurovascular Department, Azienda USL Toscana Sudest, 58100 Grosseto, Italy; (U.L.); (F.D.S.); (A.C.); (A.P.)
| | - Andrea Picchi
- Cardioneurovascular Department, Azienda USL Toscana Sudest, 58100 Grosseto, Italy; (U.L.); (F.D.S.); (A.C.); (A.P.)
| | - Fabio Lena
- Pharmacy Department, Azienda USL Toscana Sudest, 58100 Grosseto, Italy;
| | - Raffaele De Caterina
- Cardio-Thoracic and Vascular Department, Pisa University Hospital and University of Pisa, 56124 Pisa, Italy
- Fondazione VillaSerena per la Ricerca, Città Sant’Angelo, 65013 Pescara, Italy
- Correspondence: ; Tel.: +39-050-996-751
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16
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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: 0.3] [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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17
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Hoshi T, Sato A, Hiraya D, Watabe H, Takeyasu N, Nogami A, Ohigashi T, Gosho M, Ieda M, Aonuma K. Short-duration triple antithrombotic therapy for atrial fibrillation patients who require coronary stenting: results of the SAFE-A study. EUROINTERVENTION 2020; 16:e164-e172. [DOI: 10.4244/eij-d-19-00920] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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18
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Wu J, Lin S, Men C, Wang X, Wang S, Hong J, Xu D, Guo Y. Antithrombotic therapy in acute coronary syndrome and stable coronary artery disease patients with atrial fibrillation: a 3-year retrospective cohort study. Per Med 2019; 16:399-407. [PMID: 31591920 DOI: 10.2217/pme-2018-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: Acute coronary syndrome (ACS) and stable coronary artery disease (SCAD) occur frequently in patients with atrial fibrillation (AF). However, the optimal antithrombotic therapy is still debated. Methods & results: We analyzed 976 coronary artery disease patients with AF from 2013 to 2014. ACS+AF patients tend to take dual antiplatelet therapy (p < 0.001), whereas SCAD+AF patients prefer anticoagulation therapy (warfarin: p < 0.001, dabigatran: p < 0.05). Ventricular arrhythmia, congestive heart failure and ACS were the top three reasons for SCAD group patients' readmission, while reinfarction and congestive heart failure were two major factors in readmission of ACS group. Conclusion: ACS+AF group patients more likely choose dual antiplatelet therapy, whereas SCAD+AF group patients prefer anticoagulation therapy. Compared with ACS group, SCAD group had a higher rate of readmission.
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Affiliation(s)
- Jun Wu
- Department of Geriatric Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Shenglan Lin
- Ward of Cadre Care, The First Affiliated Hospital of Xiamen University, Xiamen 361003, China
| | - Chen Men
- Department of Geriatric Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Xiangming Wang
- Department of Geriatric Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Sen Wang
- Department of Geriatric Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Jian Hong
- Department of Geriatric Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Di Xu
- Department of Geriatric Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yan Guo
- Department of Geriatric Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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19
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Park H, Kim Y, Kim JS, Oh Y, Shin D, Pak H, Hwang G, Choi K, Oh S, Kim J, Lee M, Park H, Kim D, Jin E, Park J, Oh I, Shin D, Park H, Kim JH, Kim N, Ahn M, Seo B, Kim Y, Kang S, Lee J. Status of international normalized ratio control and treatment patterns in patients with nonvalvular atrial fibrillation taking vitamin K antagonist with or without antiplatelet therapy: Results from KORAFII registry. J Arrhythm 2019; 35:593-601. [PMID: 31410229 PMCID: PMC6686287 DOI: 10.1002/joa3.12183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 03/06/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Studies have shown that the concomitant use of a vitamin K antagonist (VKA) and an antiplatelet (APL) drug increased the bleeding risk and was less effective at preventing ischemic events. This study aimed to investigate the control status of international normalized ratio (INR) and the discontinuation rate of a VKA in patients taking VKA plus an APL drug compared with those taking a VKA alone. METHODS Data were extracted from the KORean Atrial Fibrillation Investigation II registry, a multicenter noninterventional prospective observational study. Nonvalvular atrial fibrillation (NVAF) patients with CHADS 2 scores ≥ 1 who newly started (within 3 months) a VKA were enrolled and followed up for 1 year. RESULTS A total of 866 NVAF patients (mean age, 67.7 years; 60.3% men) without a bleeding history were divided into the VKA+APL (n = 229) and VKA alone (n = 637) groups. During follow-up, mean INR level was lower in the VKA+APL group than in the VKA alone group (1.7 ± 0.8 vs 1.9 ± 0.9, P = 0.0005). INR levels were poorly controlled in both groups (66.1% and 64.7%, respectively). Patients in the VKA+APL group more frequently discontinued VKA than patients in the VKA alone group (28.8% vs 24.2%, P = 0.045). Major causes of VKA discontinuation were uncontrolled INR level and patient dissatisfaction or concerns. CONCLUSIONS The conditions of NVAF patients were inadequately controlled with VKA with or without an APL. These findings suggest that other antithrombotic treatment options are warranted in NVAF patients to achieve INR control.
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Affiliation(s)
- Hee‐Soon Park
- Internal MedicineKorea University College of MedicineSeoulKorea
| | - Young‐Hoon Kim
- Internal MedicineKorea University College of MedicineSeoulKorea
| | - June Soo Kim
- Internal MedicineSamsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Yong‐Seog Oh
- Internal MedicineSeoul St. Mary's HospitalThe Catholic University of KoreaSeoulKorea
| | - Dong‐Gu Shin
- Internal MedicineYeungnam University College of MedicineDaeguKorea
| | - Hui‐Nam Pak
- Internal MedicineSeverance HospitalYonsei University Health SystemSeoulKorea
| | | | - Kee‐Joon Choi
- Internal MedicineAsan Medical CenterUlsan UniversitySeoulKorea
| | - Seil Oh
- Internal MedicineSeoul National University HospitalSeoulKorea
| | - Jin‐Bae Kim
- Internal MedicineKyung Hee University Medical CenterSeoulKorea
| | - Man‐Young Lee
- Internal MedicineYeoyuido St. Mary's HospitalThe Catholic University of KoreaSeoulKorea
| | - Hyung‐Wook Park
- Internal MedicineChonnam National University HospitalGwangjuKorea
| | - Dae‐Kyeong Kim
- Internal MedicineInje University Busan Paik HospitalBusanKorea
| | - Eun‐Sun Jin
- Internal MedicineKyung Hee University Hospital at GangdongSeoulKorea
| | - Jae‐Seok Park
- Internal MedicineSejong General HospitalBucheonKorea
| | - Il‐Young Oh
- Internal MedicineSeoul National University Bundang HospitalSoengnam‐SiKorea
| | - Dae‐Hee Shin
- Internal MedicineGangneung Asan HospitalGangneungKorea
| | - Hyoung‐Seob Park
- Internal MedicineDongsan Medical CenterKeimyung UniversityDaeguKorea
| | - Jun Hyung Kim
- Internal MedicineChungnam National University College of MedicineChungnamKorea
| | - Nam‐Ho Kim
- Internal MedicineWonkwang University HospitalIksanKorea
| | - Min‐Soo Ahn
- Internal MedicineYonsei UniversityWonju Severance Christian HospitalWonjuKorea
| | - Bo‐Jeong Seo
- Outcomes Research/Real World Data, Corporate Affairs & Health and ValuePfizer Pharmaceuticals Korea Ltd.SeoulKorea
| | - Young‐Joo Kim
- Outcomes Research/Real World Data, Corporate Affairs & Health and ValuePfizer Pharmaceuticals Korea Ltd.SeoulKorea
| | - Seongsik Kang
- Internal Medicine ‐MedicalPfizer Pharmaceuticals Korea Ltd.SeoulKorea
| | - Juneyoung Lee
- Department of BiostatisticsCollege of MedicineKorea UniversitySeoulKorea
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20
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Knijnik L, Rivera M, Blumer V, Cardoso R, Fernandes A, Fernandes G, Ferreira T, Romano JG, Lambrakos LK, Cohen MG. Prevention of Stroke in Atrial Fibrillation After Coronary Stenting. Stroke 2019; 50:2125-2132. [PMID: 31303150 DOI: 10.1161/strokeaha.119.026078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The optimal antithrombotic strategy to balance thromboembolic and bleeding events, especially acute stroke, for patients with atrial fibrillation following coronary stenting remains a matter of debate. We conducted a network meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in atrial fibrillation after coronary stenting. Methods- PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials and observational studies of patients with atrial fibrillation after coronary stenting. The outcomes of interest were stroke, myocardial infarction, major adverse cardiac events, mortality, and major bleeding. A network meta-analysis was performed comparing the available antithrombotic regimens in the literature. Results- Three randomized and 15 observational studies were included, with a total of 23 478 participants. Median follow-up was 2 years. Network meta-analysis demonstrated that vitamin K antagonist plus single antiplatelet therapy or direct-acting oral anticoagulant plus single antiplatelet therapy were the most effective regimens in preventing stroke. Direct-acting oral anticoagulant regimens were associated with lower major bleeding rates than vitamin K antagonist regimens. Regimens with dual antiplatelet therapy were associated with lower rates of myocardial infarction. Vitamin K antagonist plus dual antiplatelet therapy was associated with a lower mortality and low-dose direct-acting oral anticoagulants with decreased major cardiovascular adverse events. Conclusions- Direct-acting oral anticoagulant regimens were associated with less major bleeding and major cardiovascular adverse events, but vitamin K antagonists were associated with decreased mortality and stroke. These results suggest that the decision of antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention needs to be individualized.
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Affiliation(s)
- Leonardo Knijnik
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Manuel Rivera
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.R.)
| | - Vanessa Blumer
- Cardiovascular Division, Duke University Hospital, Durham, NC (V.B.)
| | - Rhanderson Cardoso
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD (R.C.)
| | - Amanda Fernandes
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Gilson Fernandes
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Tanira Ferreira
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Jose G Romano
- Department of Neurology (J.G.R.), University of Miami Miller School of Medicine, FL
| | - Litsa K Lambrakos
- Cardiovascular Division, Department of Medicine (L.K.L., M.G.C.), University of Miami Miller School of Medicine, FL
| | - Mauricio G Cohen
- Cardiovascular Division, Department of Medicine (L.K.L., M.G.C.), University of Miami Miller School of Medicine, FL
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Park J, Choi EK, Han KD, Choi YJ, Lee SR, Cha MJ, Kang J, Park KW, Oh S, Lip GY. Antithrombotic Therapy in Patients With Atrial Fibrillation After Percutaneous Coronary Intervention During 2-Year Follow-Up, from a Nationwide Population Study. Am J Cardiol 2019; 123:1921-1926. [PMID: 30967291 DOI: 10.1016/j.amjcard.2019.03.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/03/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022]
Abstract
Patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) are recommended to receive oral anticoagulants (OAC) and concomitant antiplatelet agents followed by OAC monotherapy continued beyond a year after PCI. However, long-term prescription patterns of antithrombotic therapy in real-world clinical practice were not fully investigated. From the National Health Insurance Service database of Korea, we obtained records of patients with AF who underwent PCI between 2009 and 2013. Patients without repeated PCI or death within 2 years following the procedure were included. Prescription records of antithrombotic therapy including anticoagulants and antiplatelet agents were reviewed at 3-month intervals after discharge. We investigated 8,891 patients. At discharge, 76.1% of the patients received dual antiplatelet therapy (DAPT) and only 17.1% received OAC. Although the proportion of patients receiving DAPT gradually decreased, >70% of patients received only antiplatelet agents (DAPT or single antiplatelet therapy) a year after PCI. During the 2-year follow-up, the proportion of patients receiving OAC remained <20%, and only 1.5% of the patients received OAC monotherapy a year after PCI. Female gender, previous myocardial infarction, peripheral vascular disease, and prescription of DAPT at discharge were associated with underprescription of OAC a year after PCI. In conclusion, a significant proportion (76%) of patients with AF who underwent PCI were not prescribed OAC at discharge despite the high risk of stroke contrary to the current guidelines. Most patients continued to receive antiplatelet agents without OAC beyond the 1-year time point after PCI.
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22
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Montone RA, Niccoli G, Tufaro V, Minelli S, Russo M, Vergni F, Sommariva L, Pelliccia F, Bedogni F, Crea F. Changes in renal function and occurrence of contrast-induced nephropathy after percutaneous coronary interventions in patients with atrial fibrillation treated with non-vitamin K oral anticoagulants or warfarin. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:59-67. [PMID: 31043986 PMCID: PMC6488841 DOI: 10.5114/aic.2019.83772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 11/04/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Patients with atrial fibrillation (AF) receiving non-vitamin K oral anticoagulants (NOAC) have a slower decline in renal function than those taking warfarin. Moreover, a warfarin-related nephropathy has been described. AIM We assessed variation of estimated glomerular filtration rate (eGFR) and occurrence of contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) in patients with AF taking warfarin compared with NOAC. MATERIAL AND METHODS We retrospectively enrolled consecutive patients taking oral anticoagulation for AF undergoing PCI. The primary endpoint was variation in eGFR and serum creatinine levels within 48-72 h after PCI. The secondary endpoint was occurrence of CIN, defined as a ≥ 25% relative increase, or a ≥ 0.5 mg/dl absolute increase, in serum creatinine levels within 48-72 h. RESULTS We enrolled 420 patients (mean age: 75.0 ±5.5 years, 272 (64.7%) male), 124 (29.5%) treated with NOAC and 296 (70.5%) with warfarin. NOAC patients showed a reduced decline in renal function (eGFR change: -2.8 ±7.9 ml/min/1.73 m2 vs. -4.5 ±6.5 ml/min/1.73 m2, respectively, p = 0.02) and a smaller increase in serum creatinine levels (0.026 ±0.112 vs. 0.055 ±0.132, p = 0.032) after PCI compared with warfarin. In the multivariate linear regression model independent predictors of eGFR changes were diabetes, baseline eGFR ≤ 60 ml/min/1.73 m2 and warfarin use. Occurrence of CIN did not differ between NOAC and warfarin patients (13 (10.5%) vs. 46 (15.5%), p = 0.22). CONCLUSIONS Patients with AF taking NOAC have a reduced decline in renal function after PCI compared with warfarin. The NOAC may be a reasonable option for patients with a high risk of developing CIN.
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Affiliation(s)
- Rocco A. Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vincenzo Tufaro
- Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Silvia Minelli
- Interventional Cardiology, Belcolle Hospital, Viterbo, Italy
| | - Michele Russo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federico Vergni
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Sommariva
- Interventional Cardiology, Belcolle Hospital, Viterbo, Italy
| | | | - Francesco Bedogni
- Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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23
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Mantis C, Alexopoulos D. Antithrombotic treatment in atrial fibrillation patients undergoing PCI: Is dual therapy the winner? Thromb Res 2019; 176:133-139. [PMID: 30826397 DOI: 10.1016/j.thromres.2019.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/20/2019] [Accepted: 02/20/2019] [Indexed: 11/16/2022]
Abstract
Approximately 7% of patients undergoing percutaneous coronary intervention (PCI) with stent implantation have atrial fibrillation. The optimal antithrombotic treatment in such of patients remains one of the most challenging and difficult scenarios in Cardiology. Triple antithrombotic therapy (TAT), consisting of dual antiplatelet therapy plus an oral anticoagulant, has been used for decades in order to reduce ischemic and thromboembolic events, while significantly increasing the risk for severe bleeding. Recently, results of several clinical trials suggest that the use of dual antithrombotic therapy (DAT), consisting of single antiplatelet therapy plus an oral anticoagulant, reduces the risk of bleeding, while maintaining the same level of efficacy as compared to TAT. These data have been interpreted in a variety of ways, often giving conflicting recommendations and leaving many unanswered questions on the optimal antithrombotic treatments of patients with atrial fibrillation who undergo PCI. DAT consisting of a non-vitamin K antagonist oral anticoagulant and clopidogrel, while omitting aspirin from the immediate post discharge period, appears as an attractive, simplified strategy for most patients and supported by many experts in the field. In this review we aim to better define the role of DAT versus TAT in atrial fibrillation patients undergoing PCI and analyze remaining controversial issues and future expectations.
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Affiliation(s)
- Christos Mantis
- Cardiology Department, Konstantopoulio General Hospital, Athens, Greece
| | - Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece.
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Temporal trends in prevalence and antithrombotic treatment among Asians with atrial fibrillation undergoing percutaneous coronary intervention: A nationwide Korean population-based study. PLoS One 2019; 14:e0209593. [PMID: 30645601 PMCID: PMC6333333 DOI: 10.1371/journal.pone.0209593] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Accepted: 12/07/2018] [Indexed: 11/23/2022] Open
Abstract
Background We investigated the recent 10-year trends in the number of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in relation to prescription patterns of antithrombotic therapy. Methods We analyzed the annual prevalence of PCI and patterns of antithrombotic therapy after PCI, including antiplatelets and oral anticoagulants (vitamin K antagonists and non-vitamin K antagonist oral anticoagulants [NOACs]), in patients with AF between 2006 and 2015 by using the Korean National Health Insurance Service database. Independent factors associated with triple therapy (oral anticoagulant plus dual antiplatelet) prescription were assessed using multivariable logistic regression analysis. Results The number of patients with AF undergoing PCI increased gradually from 2006 (n = 2,140) to 2015 (n = 3,631) (ptrend<0.001). In 2006, only 22.7% of patients received triple therapy after PCI although 96.2% of them were indicated for anticoagulation (CHA2DS2-VASc score ≥2). The prescription rate of triple therapy increased to 38.3% in 2015 (ptrend<0.001), which was mainly attributed to a recent increment of NOAC-based triple therapy from 2013 (17.5% in 2015). Previous ischemic stroke or systemic embolism, old age, hypertension, and congestive heart failure were significantly associated with a higher triple therapy prescription rate, whereas previous myocardial infarction, PCI, and peripheral arterial disease were associated with triple therapy underuse. Conclusions From 2006 to 2015, the number of patients with AF undergoing PCI and the prescription rate of triple therapy increased gradually with a recent increment of NOAC-based antithrombotic therapy from 2013. Previous myocardial infarction, peripheral artery disease, and PCI were associated with underuse of triple therapy.
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25
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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: 0.2] [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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26
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Joung B, Lee JM, Lee KH, Kim TH, Choi EK, Lim WH, Kang KW, Shim J, Lim HE, Park J, Lee SR, Lee YS, Kim JB. 2018 Korean Guideline of Atrial Fibrillation Management. Korean Circ J 2018; 48:1033-1080. [PMID: 30403013 PMCID: PMC6221873 DOI: 10.4070/kcj.2018.0339] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/08/2018] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population. The Korean Heart Rhythm Society organized a Korean AF Management Guideline Committee and analyzed all available studies regarding the management of AF, including studies on Korean patients. This guideline is based on recent data of the Korean population and the recent guidelines of the European Society of Cardiology, European Association for Cardio-Thoracic Surgery, American Heart Association, and Asia Pacific Heart Rhythm Society. Expert consensus or guidelines for the optimal management of Korean patients with AF were achieved after a systematic review with intensive discussion. This article provides general principles for appropriate risk stratification and selection of anticoagulation therapy in Korean patients with AF. This guideline deals with optimal stroke prevention, screening, rate and rhythm control, risk factor management, and integrated management of AF.
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Affiliation(s)
- Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
| | - Jung Myung Lee
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Ki Hong Lee
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Tae Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
| | - Eue Keun Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Woon Kang
- Division of Cardiology, Eulji University College of Medicine, Daejeon, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hong Euy Lim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Junbeom Park
- Department of Cardiology, Ewha Woman University, Seoul, Korea
| | - So Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Soon Chun Hyang University Hospital, Seoul, Korea
| | - Young Soo Lee
- Division of Cardiology, Department of Internal Medicine, Daegu Catholic University, Daegu, Korea
| | - Jin Bae Kim
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Medical College, Seoul, Korea
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27
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Bunmark W, Jinatongthai P, Vathesatogkit P, Thakkinstian A, Reid CM, Wongcharoen W, Chaiyakunapruk N, Nathisuwan S. Antithrombotic Regimens in Patients With Percutaneous Coronary Intervention Whom an Anticoagulant Is Indicated: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2018; 9:1322. [PMID: 30510510 PMCID: PMC6252311 DOI: 10.3389/fphar.2018.01322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 10/29/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Patients undergoing percutaneous coronary intervention (PCI) who require anticoagulant therapy are at increased risk of bleeding. The optimal regimen for these patients is uncertain. This study aimed to compare safety and efficacy of antithrombotic regimens used in patients undergoing PCI with concomitant anticoagulant therapy. Methods: A systematic review and network meta-analysis was performed among studies comparing antithrombotic regimens for anticoagulated patients undergoing PCI. The primary outcome of interest was major bleeding. The secondary outcomes were coronary events. The reference intervention was classic triple therapy (aspirin plus clopidogrel plus VKA). Cluster rank incorporating risk (major bleeding) and benefit (all-cause death) was performed to identify the most appropriate regimen(s). Results: There were 3 RCTs (6 interventions) and 29 non-RCTs (8 interventions) that met the inclusion criteria with 22,179 patients. Network meta-analysis of RCTs indicated that dual therapy (DT), either with vitamin K antagonist (VKA) or direct anticoagulant (DOAC) plus an antiplatelet, significantly reduced the risk of major bleeding compared to triple therapy (TT) [pooled RR of 0.51 (0.30-0.87) and 0.68 (0.49-0.94), respectively]. In addition, VKA-DT significantly reduced the risk of all-cause death compared to TT [pooled RR of 0.40 (0.17-0.93)]. Results from network meta-analysis of non-RCT paralleled that of RCTs. No significant differences of coronary events were found. Conclusions: In conclusion, for anticoagulated patients undergoing PCI, dual therapy, either with warfarin or DOAC plus an antiplatelet, should be considered due to its optimal balance on efficacy and safety.
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Affiliation(s)
- Wipharak Bunmark
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Peerawat Jinatongthai
- Pharmacy Practice Division, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
| | - Prin Vathesatogkit
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Christopher M Reid
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,School of Public Health, Curtin University, Perth, WA, Australia
| | - Wanwarang Wongcharoen
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research (CPOR), Naresuan University, Phitsanulok, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor, Malaysia.,School of Pharmacy, University of Wisconsin, Madison, WI, United States.,Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
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28
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Leggio M, Fusco A, Severi P, Lombardi M, Caldarone E, D'Emidio S, Armeni M, Mereu D, Bendini MG, Mazza A. Antithrombotic Therapy After Percutaneous Coronary Intervention in Atrial Fibrillation: The Triple Trouble. Drugs 2018; 78:1309-1319. [PMID: 30132258 DOI: 10.1007/s40265-018-0957-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
One of the most common conundrums in all cardiovascular medicine pertains to the care of patients with atrial fibrillation after percutaneous coronary intervention, because of both dual antiplatelet therapy and oral anticoagulant therapy would seem to be necessary to reduce risks of stent thrombosis and thromboembolism, respectively, but also with an inevitable trade-off of more bleeding. Patients who require triple therapy are at high risk of both ischaemia and bleeding; therefore, defining a personalised secondary prevention strategy aimed at achieving the best net clinical benefit is essential. The good news is that we have entered an era of increased perceived and tangible safety that applies to both non-vitamin K-antagonist oral anticoagulants and newer drug-eluting stents. Even if the consistency across the major trials and the significantly lower risk of bleeding with dual therapy make it hard to argue that triple therapy should be used routinely, the aggregate evidence suggests that the net clinical benefit of dual therapy should give cardiologists confidence to drop aspirin when they are using a contemporary percutaneous coronary intervention strategy with drug-eluting stents. Waiting for more randomised trials and meta-analyses, for the time being, in patients not in clinical trials, full-dose oral triple therapy with dual antiplatelet agents and full-dose anticoagulation should be avoided as a routine practice, and the choice of the proper, that is, safer, oral anticoagulant, namely a non-vitamin K-antagonist oral anticoagulant, may be regarded by now as an additional bleeding avoiding strategy in patients with atrial fibrillation undergoing percutaneous coronary intervention.
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Affiliation(s)
- Massimo Leggio
- Department of Medicine and Rehabilitation, Cardiac Rehabilitation Operative Unit, San Filippo Neri Hospital, Salus Infirmorum Clinic, Via della Lucchina 41, 00135, Rome, Italy.
| | | | - Paolo Severi
- Department of Medicine and Rehabilitation, Cardiac Rehabilitation Operative Unit, San Filippo Neri Hospital, Salus Infirmorum Clinic, Via della Lucchina 41, 00135, Rome, Italy.,Physical Medicine and Neurorehabilitation Operative Unit, Salus Infirmorum Clinic, Rome, Italy
| | - Mario Lombardi
- Physical Medicine and Neurorehabilitation Operative Unit, Salus Infirmorum Clinic, Rome, Italy
| | - Elisa Caldarone
- Physical Medicine and Neurorehabilitation Operative Unit, Salus Infirmorum Clinic, Rome, Italy
| | - Stefania D'Emidio
- Physical Medicine and Neurorehabilitation Operative Unit, Salus Infirmorum Clinic, Rome, Italy
| | - Massimo Armeni
- Department of Research, EDUCAM (C.R.O.M.O.N., S.Os.I., A.I.R.O.P.), Rome, Italy
| | - Daniela Mereu
- Physical Medicine and Neurorehabilitation Operative Unit, Salus Infirmorum Clinic, Rome, Italy
| | | | - Andrea Mazza
- Cardiology Division, Santa Maria della Stella Hospital, Orvieto, Italy
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29
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Zhang Y, Zhang L, Zheng H, Chen H. Effects of atrial fibrillation on complications and prognosis of patients receiving emergency PCI after acute myocardial infarction. Exp Ther Med 2018; 16:3574-3578. [PMID: 30233710 PMCID: PMC6143848 DOI: 10.3892/etm.2018.6640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 08/02/2018] [Indexed: 12/28/2022] Open
Abstract
The effects of atrial fibrillation on complications and prognosis of patients receiving emergency percutaneous coronary intervention after acute myocardial infarction (AMI) were investigated. Eighty AMI patients treated with interventional vascular recanalization in the Affiliated Hospital of Weifang Medical University (Weifang, China) from July 2015 to October 2016 were selected, including 40 patients complicated with atrial fibrillation before operation (control group) and 40 patients without atrial fibrillation before operation (observation group). The systolic blood pressure, diastolic blood pressure, heart rate, arrhythmia and common complications after MI were compared. Changes in the coronary artery thrombolysis in myocardial infarction (TIMI) flow grade and left ventricular ejection fraction (LVEF) of patients were also recorded. Moreover, changes in brain natriuretic peptide (BNP) levels were compared. The recovery time of myocardial enzyme and total troponin in both groups was recorded. The systolic and diastolic blood pressure in the observation group were significantly higher than those in the control group (p<0.05). During the intervention, the total proportion of patients with ventricular arrhythmia, atrial arrhythmia, atrioventricular block and sinus tachycardia in the observation group was significantly lower than that in the control group (p<0.05). The total proportion of common complications after MI in the observation group was obviously lower than that in the control group (p<0.05). Coronary artery TIMI flow grades and LVEFs in the observation group were obviously higher than those in the control group. BNP levels in the observation group were significantly lower than those in the control group. The recovery time of myocardial enzyme and total troponin in the observation group was significantly earlier than that in the control group. Atrial fibrillation has a certain negative effect on the circulatory function in patients with AMI after the interventional therapy, and the proportions of arrhythmia and complications in patients after MI are increased at the same time, so the postoperative recovery of patients is slow with many complications.
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Affiliation(s)
- Yingchun Zhang
- Department of Emergency, Affiliated Hospital of Weifang Medical University, Weifang, Shandong 261031, P.R. China
| | - Lingzhi Zhang
- Department of Stomatology, Affiliated Hospital of Weifang Medical University, Weifang, Shandong 261031, P.R. China
| | - Hongzhi Zheng
- Department of Public Health, Affiliated Hospital of Weifang Medical University, Weifang, Shandong 261031, P.R. China
| | - Hongfen Chen
- Department of Emergency, Affiliated Hospital of Weifang Medical University, Weifang, Shandong 261031, P.R. China
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30
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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: 30.0] [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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Matsumura-Nakano Y, Shiomi H, Morimoto T, Shizuta S, Yamaji K, Watanabe H, Yoshikawa Y, Taniguchi T, Kawaji T, Natsuaki M, Akasaka T, Hanaoka K, Kadota K, Kozuma K, Tanabe K, Nakagawa Y, Muramatsu T, Morino Y, Ando K, Kimura T. Sex Differences in Long-Term Clinical Outcomes in Patients With Atrial Fibrillation Undergoing Coronary Stent Implantation. Circ J 2018; 82:1754-1762. [PMID: 29593146 DOI: 10.1253/circj.cj-17-1278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients with concomitant atrial fibrillation (AF) and coronary stenting are at high risk for both cardiovascular and bleeding events. We aimed to evaluate the influence of sex on long-term clinical outcomes in this patient subset.Methods and Results:We identified 1,450 patients with AF and coronary stenting in a patient-level pooled database from 3 Japanese studies, and compared 3-year clinical outcomes between men and women (n=1,075, and n=375, respectively). The cumulative 3-year incidence of all-cause death was significantly higher in women than in men (26.5% vs. 17.2%, log-rank P<0.001), although after adjusting for confounders, the excess mortality risk of women relative to men was no longer significant (hazard ratio (HR): 1.12, 95% confidence interval (CI): 0.85-1.46, P=0.42). There were no significant differences in the adjusted 3-year risks for myocardial infarction or stroke between men and women (HR: 1.25, 95% CI: 0.62-2.40, P=0.52, and HR: 1.15, 95% CI: 0.75-1.74, P=0.52, respectively). However, both the cumulative 3-year incidence of and adjusted risk for major bleeding were significantly higher in women than in men (17.0% vs. 11.3%, log-rank P=0.002, and HR: 1.47, 95% CI: 1.03-2.07, P=0.03). CONCLUSIONS Among patients with concomitant AF and coronary stenting, there were no significant differences in the adjusted 3-year risks for all-cause death, myocardial infarction, and stroke between men and women. However, women as compared with men were associated with excess adjusted risk for major bleeding.
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Affiliation(s)
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Komura Memorial Hospital
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuma Kawaji
- Department of Cardiovascular Medicine, Mitsubishi Kyoto Hospital
| | | | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University Hospital
| | | | | | - Ken Kozuma
- Division of Cardiology, Teikyo University Hospital
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | | | | | - Kenji Ando
- Department of Cardiovascular Medicine, Komura Memorial Hospital
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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32
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Optimum Antithrombotic Therapy in Patients Requiring Long-Term Anticoagulation and Undergoing Percutaneous Coronary Intervention. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5690640. [PMID: 29770334 PMCID: PMC5889881 DOI: 10.1155/2018/5690640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/14/2017] [Indexed: 02/07/2023]
Abstract
Management of patients on long-term anticoagulation requiring percutaneous coronary intervention is challenging. Triple therapy with oral anticoagulant and dual antiplatelet therapy is the standard of care. However, there is no strong evidence to support this strategy. There is emerging data regarding the safety and efficacy of dual therapy with oral anticoagulant and single antiplatelet therapy in these patients. In this comprehensive review we highlight available evidence regarding various antithrombotic regimens' efficacy and safety in patient with coronary artery disease undergoing percutaneous coronary intervention with long-term anticoagulation therapy requirements.
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33
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Impact of quality of anticoagulation control on outcomes in patients with atrial fibrillation taking aspirin: An analysis from the SPORTIF trials. Int J Cardiol 2018; 252:96-100. [DOI: 10.1016/j.ijcard.2017.10.091] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/09/2017] [Accepted: 10/23/2017] [Indexed: 11/23/2022]
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34
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Li JX, Li Y, Yan SJ, Han BH, Song ZY, Song W, Liu SH, Guo JW, Yin S, Chen YP, Xia DJ, Li X, Li XQ, Jin EZ. Optimal antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: A systemic review and meta-analysis. Biomed Rep 2018; 8:138-147. [PMID: 29435272 PMCID: PMC5778825 DOI: 10.3892/br.2017.1036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/17/2017] [Indexed: 01/11/2023] Open
Abstract
A challenge for antithrombotic treatment is patients who present with atrial fibrillation (AF) and acute coronary syndrome, particularly in patients who have undergone coronary percutaneous intervention with stenting (PCIS). In the present study, a total of nine observational trials published prior to July 2017 that investigated the effects of dual antiplatelet therapy (DAPT; aspirin + clopidogrel) and triple oral antithrombotic therapy (TOAT; DAPT + warfarin) among patients with AF concurrent to PCIS were collected from the Medline, Cochrane and Embase databases and conference proceedings of cardiology, gastroenterology and neurology meetings. A meta-analysis was performed using fixed- or random-effect models according to heterogeneity. The subgroups were also analyzed on the occurrence of major adverse cardiac events (MACE), stroke and bleeding events in the two treatment groups. Analysis of baseline characteristics indicated that there was no significant difference in the history of coexistent disease or conventional therapies between the DAPT and TOAT groups. The primary end point incidence was 2,588 patients in the DAPT group (n=13,773) and 871 patients in the TOAT group (n=5,262) following pooling of all nine trials. There was no statistically significant difference in the incidence of primary end points between the DAPT and TOAT groups. Odds ratio (OR)=0.96, 95% confidence interval (CI)=0.73-1.27, P=0.79, with heterogeneity between trials (I2=82%, P<0.00001). Subsequently, on subgroup analysis, the results indicated no increased risk of major bleeding or ischemic stroke in the DAPT or TOAT group. However, compared with the TOAT group, there was an apparent increased risk of MACE plus ischemic stroke in the DAPT group (OR=1.62, 95% CI=1.43-1.83, P<0.00001) with heterogeneity between trials (I2=70%, P=0.01). In conclusion, the present meta-analysis suggests that TOAT (aspirin + clopidogrel + warfarin) therapy for patients with AF concurrent to PCIS significantly reduced the risk of MACE and stroke compared with DAPT (aspirin + clopidogrel) therapy. Further randomized controlled clinical trials are required to confirm the efficacy of the optimal antithrombotic therapy in patients with AF following PCIS.
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Affiliation(s)
- Jing-Xiu Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yang Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Shu-Jun Yan
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Bai-He Han
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Zhao-Yan Song
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Wei Song
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Shi-Hao Liu
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Ji-Wei Guo
- Department of Cardiology, Harbin First Hospital, Harbin, Heilongjiang 150001, P.R. China
| | - Shuo Yin
- Department of Pharmacy, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Ye-Ping Chen
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - De-Jun Xia
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Xin Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Xue-Qi Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - En-Ze Jin
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
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35
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Batra G, Friberg L, Erlinge D, James S, Jernberg T, Svennblad B, Wallentin L, Oldgren J. Antithrombotic therapy after myocardial infarction in patients with atrial fibrillation undergoing percutaneous coronary intervention. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2017; 4:36-45. [DOI: 10.1093/ehjcvp/pvx033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/03/2017] [Indexed: 12/17/2022]
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36
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Zhu W, Guo L, Liu F, Wan R, Shen Y, Lip GYH, 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: 0.9] [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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37
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Capodanno D, Angiolillo DJ. Triple Antithrombotic Therapy at the Intercept Between Threats and Opportunities. JACC Cardiovasc Interv 2017; 10:1086-1088. [DOI: 10.1016/j.jcin.2017.03.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 03/02/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
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