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Gong X, Hua R, Bai J, Wu T, Wang Q, Zhang J, Zhang W, Ying L, Ke Y, Wang X, Zhang X, Liu K, Chen Y, Zhang B, Dong P, Xiao J, Li C, Zhu L, Li C. Rationale and design of the optimal antithrombotic treatment for acute coronary syndrome patients with concomitant atrial fibrillation and implanted with new-generation drug-eluting stent: OPtimal management of anTIthroMbotic Agents (OPTIMA)-4 trial. Clin Cardiol 2023. [PMID: 37191146 DOI: 10.1002/clc.24025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND About 5%-15% of acute coronary syndrome (ACS) patients undergoing stent implantation have concomitant atrial fibrillation and need both antiplatelet and anticoagulant therapies. The optimal antithrombotic regimen remains uncertain in this scenario. HYPOTHESIS A multicenter randomized controlled trial (OPtimal management of anTIthroMbotic Agents [OPTIMA]-4) is designed to test the hypothesis that, for ACS patients with concomitant nonvalvular atrial fibrillation (NVAF) and having low-to-moderate risk of bleeding, clopidogrel is comparable in efficacy but superior in safety compared to ticagrelor while being used in combination with dabigatran after new-generation drug-eluting stent (DES) implantation. METHODS ACS patients who have low-to-moderate risk of bleeding (e.g., HAS-BLED score ≤ 2) and require anticoagulation therapy (CHA2 DS2 -VASc score ≥ 2) will be recruited after implantation of new-generation DES. A total of 1472 eligible patients will be randomly assigned to receive a 12-month dual antithrombotic treatment of either clopidogrel 75 mg daily or ticagrelor 90 mg twice daily in combination with dabigatran 110 mg twice daily. Participants will be followed up for 12 months after randomization. The primary efficacy endpoint is a composite of cardiovascular death, myocardial infarction, unplanned revascularization, ischemic stroke, and systemic thromboembolism. The primary safety endpoint is set as major bleeding or clinically relevant nonmajor bleeding defined by the International Society of Thrombosis and Hemostasis. The enrollment and follow-up have been launched. RESULTS The first enrollment occurred on March 12, 2018. The recruitment is anticipated to be completed before December 31, 2024. CONCLUSIONS The OPTIMA-4 trial offers an opportunity to assess the optimal dual antithrombotic regimen in ACS patients with concomitant NVAF after the implantation of new-generation DES.
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Affiliation(s)
- Xiaoxuan Gong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Rui Hua
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jianling Bai
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Tianyu Wu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qin Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinhua Zhang
- The Pharmaceutical Department, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wenhao Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lianghong Ying
- Department of Cardiology, The Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an Second People's Hospital, Huai'an, China
| | - Yongsheng Ke
- Department of Cardiology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xiaoyan Wang
- Department of Cardiology, The Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Xiwen Zhang
- Department of Cardiology, The Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Kun Liu
- Department of Cardiology, The First People's Hospital of Lianyungang, Lianyungang, China
| | - Yan Chen
- Department of Cardiology, Taishan People's Hospital, Taishan, China
| | - Boqing Zhang
- Department of Cardiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Peng Dong
- Department of Cardiology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Jianqiang Xiao
- Department of Cardiology, Changzhou Wujin People's Hospital, Changzhou, China
| | - Changling Li
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Li Zhu
- Department of Cardiology, Taizhou People's Hospital, Taizhou, China
| | - Chunjian Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Ozaki Y, Kawai H, Muramatsu T, Harada M, Takahashi H, Ishii H, Maekawa Y, Ismail TF, Amano T, Izawa H, Murohara T. Rationale and Design of Registry for Estimation of Warfarin and Rivaroxaban in Atrial Fibrillation Patients With Coronary Stent Implantation (REWRAPS). Circ Rep 2022; 4:604-608. [DOI: 10.1253/circrep.cr-22-0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/25/2022] [Accepted: 10/02/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yukio Ozaki
- Department of Cardiology, Fujita Health University (FHU) School of Medicine
| | - Hideki Kawai
- Department of Cardiology, Fujita Health University (FHU) School of Medicine
| | - Takashi Muramatsu
- Department of Cardiology, Fujita Health University (FHU) School of Medicine
| | - Masahide Harada
- Department of Cardiology, Fujita Health University (FHU) School of Medicine
| | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine
| | - Tevfik F. Ismail
- Department of Cardiology, Fujita Health University (FHU) School of Medicine
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University Hospital
| | - Hideo Izawa
- Department of Cardiology, Fujita Health University (FHU) School of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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3
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Wang MT, Hung CC, Lin KC, Mar GY, Kuo SH, Chiang CH, Cheng CC, Kuo FY, Liang HL, Huang WC. Comparison of effects of triple antithrombotic therapy and dual antiplatelet therapy on long-term outcomes of acute myocardial infarction. Heart Vessels 2020; 36:345-358. [PMID: 33033854 DOI: 10.1007/s00380-020-01708-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 09/25/2020] [Indexed: 12/26/2022]
Abstract
Warfarin is an alternate choice for patients who are not eligible for non-vitamin K oral anticoagulants after acute myocardial infarction (AMI). This study aimed to compare the long-term outcome of triple antithrombotic therapy (TAT) with that of dual antiplatelet therapy (DAPT) after AMI. This was a nationwide, propensity score-matched, case-control study of 186,112 first AMI patients, of whom 2,825 received TAT comprising aspirin, clopidogrel, and warfarin. Propensity score matching in a ratio of 1:4 by age, sex, comorbidities, and treatment was adopted, Finally, 2,813 AMI patients and 11,252 matched controls that were administered TAT and DAPT (aspirin and clopidogrel), respectively, were included in our analysis. The 12-year overall survival rate did not differ between both strategies (P = .3167). TAT was beneficial in old age (hazard ratio [HR] = 0.92), female sex (HR = 0.86), atrial fibrillation (AF) (HR = 0.80), hypertension (HR = 0.92), cerebrovascular accident (HR = 0.90), and in the absence of percutaneous coronary intervention (HR = 0.79). TAT reduced the rate of recurrent myocardial infarction (P = .0108) but did not affect the rate of stroke (P = .4867), gastrointestinal bleeding (P = .3889), or intracranial hemorrhage (ICH) (P = .3449). TAT reduces the incidence of recurrent myocardial infarction and does not increase the risk of major bleeding, while compared to DAPT.
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Affiliation(s)
- Mei-Tzu Wang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Cheng Chung Hung
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Guang-Yuan Mar
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Shu-Hung Kuo
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Cheng-Hung Chiang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chin-Chang Cheng
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Feng-You Kuo
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Hsing-Li Liang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan.
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4
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Wang YH, Kao HL, Wang CC, Lin SY, Lin FJ. Comparative Effectiveness and Safety of Antithrombotic Therapy in Atrial Fibrillation Patients Presenting with Acute Coronary Syndrome or Percutaneous Coronary Intervention. ACTA CARDIOLOGICA SINICA 2019; 35:508-521. [PMID: 31571800 PMCID: PMC6760126 DOI: 10.6515/acs.201909_35(5).20190311a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/11/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND There remains insufficient evidence to determine the optimal antithrombotic strategy in atrial fibrillation (AF) patients presenting with acute coronary syndrome (ACS) or percutaneous coronary interventions (PCIs), especially in Asian populations. OBJECTIVES This study aimed to examine the real-world patterns of antithrombotic treatment among these patients and to compare the effectiveness and safety of different antithrombotic regimens. METHODS A retrospective cohort study was conducted in AF patients presenting with a new ACS or PCI during 2006/1/1-2016/4/1. Three antithrombotic regimens were compared: dual antiplatelet therapy (DAPT, as the reference group), triple therapy (TT: DAPT plus an oral anticoagulant), and dual therapy (DT: single antiplatelet plus an oral anticoagulant). The outcomes of interest were major adverse cardiac and cerebrovascular events (MACCEs) and bleeding. Treatment effect was estimated using a Cox proportional hazards model. Inverse probability of treatment weighting was used to balance baseline characteristics among comparison groups. RESULTS Overall, 532 patients were included. At discharge from the index hospitalization, DAPT was the most common antithrombotic therapy, followed by TT and DT. No significant difference in MACCEs was found among the different antithrombotic regimens. However, DT was associated with a lower risk of any bleeding [adjusted hazard ratio 0.20 (95% confidence interval, 0.06-0.75)] than DAPT. CONCLUSIONS In the study population, DAPT was the most commonly prescribed antithrombotic regimen for cardio-cerebrovascular disease prevention. The effectiveness outcomes were comparable across different antithrombotic strategies. The lower risk of bleeding with DT compared with DAPT warrants further investigation.
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Affiliation(s)
- Yueh-Hsin Wang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University
| | - Hsien-Li Kao
- Department of Internal Medicine, National Taiwan University Hospital
| | - Chi-Chuan Wang
- School of Pharmacy, College of Medicine, National Taiwan University
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Shin-Yi Lin
- School of Pharmacy, College of Medicine, National Taiwan University
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Ju Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University
- School of Pharmacy, College of Medicine, National Taiwan University
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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5
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Atti V, Turagam MK, Garg J, Velagapudi P, Patel NJ, Basir MB, Mujer MTP, Rayamajhi S, Abela GS, Koerber S, Gopinnathanair R, Lakkireddy D. Efficacy and safety of single vs dual antiplatelet therapy in patients on anticoagulation undergoing percutaneous coronary intervention: A systematic review and meta‐analysis. J Cardiovasc Electrophysiol 2019; 30:2460-2472. [DOI: 10.1111/jce.14132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/23/2019] [Accepted: 07/29/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Varunsiri Atti
- Department of Medicine Michigan State University‐Sparrow Hospital East Lansing Michigan
| | - Mohit K. Turagam
- Department of Cardiovascular Diseases Icahn School of Medicine at Mount Sinai New York City New York
| | - Jalaj Garg
- Department of Cardiovascular Diseases Icahn School of Medicine at Mount Sinai New York City New York
| | - Poonam Velagapudi
- Department of Cardiovascular Diseases University of Nebraska Medical Center Omaha Nebraska
| | - Nileshkumar J Patel
- Department of Cardiovascular Diseases Icahn School of Medicine at Mount Sinai New York City New York
| | - Mir B Basir
- Department of Cardiovascular Diseases Henry Ford Health System Detroit Michigan
| | - Mark TP Mujer
- Department of Medicine Michigan State University‐Sparrow Hospital East Lansing Michigan
| | - Supratik Rayamajhi
- Department of Medicine Michigan State University‐Sparrow Hospital East Lansing Michigan
| | - George S Abela
- Division of Cardiovascular Diseases, Department of Medicine Michigan State University East Lansing Michigan
| | - Scott Koerber
- Department of Cardiovascular Diseases University of South Carolina Medical Center Charleston South Carolina
| | - Rakesh Gopinnathanair
- Department of Cardiovascular Diseases Kansas City Heart Rhythm Institute and Research Foundation Kansas City Missouri
| | - Dhanunjaya Lakkireddy
- Department of Cardiovascular Diseases Kansas City Heart Rhythm Institute and Research Foundation Kansas City Missouri
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6
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Dahal K, Mustafa U, Sharma SP, Apte N, Bogabathina H, Hanna M, Watti H, Azrin M, Lee J, Mina G, Katikaneni P, Modi K. Ischemic and bleeding outcomes of triple therapy in patients on chronic anticoagulation undergoing percutaneous coronary intervention: A meta-analysis of randomized trials. JRSM Cardiovasc Dis 2019; 8:2048004019885572. [PMID: 31700620 PMCID: PMC6826915 DOI: 10.1177/2048004019885572] [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: 02/26/2019] [Revised: 08/07/2019] [Accepted: 10/08/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Triple therapy (TT) that includes oral anticoagulation and dual antiplatelet therapy is recommended in patients who are on chronic anticoagulation and undergo percutaneous coronary intervention (PCI). The randomized clinical trials (RCTs) comparing the effectiveness and safety of TT compared to double therapy (DT), which consists of an oral anticoagulation and one of the P2Y12 inhibitors, have shown increased risk of bleeding; however, none of the individual studies were powered to show a difference in ischemic outcomes. To compare the clinical outcomes of TT and DT, we performed this meta-analysis of RCTs. METHODS Electronic search of PubMed, EMBASE and Cochrane CENTRAL databases was performed for RCTs comparing TT and DT in patients who were on oral anticoagulation (Vitamin K antagonist or non-vitamin K antagonist oral anticoagulant) who underwent PCI. All-cause and cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST) and TIMI major and minor bleeding were the major outcomes. RESULTS An analysis of 5 trials including 10,592 total patients showed that TT, compared to DT, resulted in non-significant difference in risk of all-cause [odds ratio (OR); 1.14;95% confidence interval (CI):(0.80-1.63); P = 0.46) and cardiovascular mortality [1.43(0.58-3.36); P = 0.44], MI [0.88 (0.64-1.21); P = 0.42], stroke [1.10(0.75-1.62); P = 0.63] and ST [0.82(0.46-1.45); P = 0.49]. TT, compared to DT resulted in higher risk of TIMI major bleeding [1.61(1.09-2.37); P = 0.02], TIMI minor bleeding [1.85(1.23-2.79); P = 0.003] and TIMI major and minor bleeding [1.81 (1.38-2.38); P < 0.0001; I2 = 52%]. CONCLUSION Compared to DT, the patients receiving TT are at a higher risk of major and minor bleeding with no survival benefit or impact on thrombotic outcomes.
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Affiliation(s)
- Khagendra Dahal
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
- Division of Cardiology, Calhoun Cardiovascular Center, University of Connecticut Health Center, Farmington, CT, USA
| | - Usman Mustafa
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Sharan P Sharma
- Division of Cardiology, Garden City Hospital, Michigan State University, Garden City, MI, USA
| | - Nachiket Apte
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Hari Bogabathina
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Magdy Hanna
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Hussam Watti
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Michael Azrin
- Division of Cardiology, Calhoun Cardiovascular Center, University of Connecticut Health Center, Farmington, CT, USA
| | - Juyong Lee
- Division of Cardiology, Calhoun Cardiovascular Center, University of Connecticut Health Center, Farmington, CT, USA
| | - Goerge Mina
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Pavan Katikaneni
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Kalgi Modi
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Dual versus triple antithrombotic therapy after percutaneous coronary intervention or acute coronary syndrome in patients with indication for anticoagulation: an updated meta-analysis. Coron Artery Dis 2018; 29:670-680. [PMID: 30222595 DOI: 10.1097/mca.0000000000000660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND For patients who have an indication for anticoagulation, it is controversial whether dual therapy with an oral anticoagulant and single antiplatelet agent can be used after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) instead of triple therapy with an oral anticoagulant and dual antiplatelet therapy. PARTICIPANTS AND METHODS Twelve observational studies and four clinical trials were identified from three electronic databases from their inception to December, 2017. Pooled estimates were calculated using a random-effects model for meta-analysis. RESULTS Compared with the triple therapy, dual therapy was associated with significantly lower risk of major bleeding [relative risk (RR), 0.63; 95% confidence interval (CI), 0.50-0.80] without statistically significant increase in major adverse cardiac events (RR, 1.04; 95% CI, 0.84-1.29), all-cause death (RR, 1.15; 95% CI, 0.77-1.71), cardiac death (RR, 1.04; 95% CI, 0.67-1.61), myocardial infarction (RR, 1.25; 95% CI, 0.98-1.59), stroke (RR, 1.27; 95% CI, 0.79-2.06), stent thrombosis (RR, 1.52; 95% CI, 0.96-2.41), and repeat revascularization (RR, 1.15; 95% CI, 0.87-1.52). Although risks of myocardial infarction and stent thrombosis were marginally higher in the dual therapy group, this trend was attenuated after excluding studies that exclusively included patients undergoing PCI for ACS, but not stable coronary artery disease. CONCLUSION Dual therapy may be a reasonable alternative to triple therapy after PCI in patients with indication for chronic anticoagulation. However, further studies are needed to investigate efficacy of dual therapy, especially in the patients with higher ischemic risk, such as in ACS.
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8
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Dual versus triple therapy in patients on oral anticoagulants and undergoing coronary stent implantation: A systematic review and meta-analysis. Int J Cardiol 2018; 273:80-87. [PMID: 30115419 DOI: 10.1016/j.ijcard.2018.08.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/29/2018] [Accepted: 08/08/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS There is contrasting evidence regarding the optimal antithrombotic regimen after percutaneous coronary stent implantation in patients on oral anticoagulants. A systematic review and meta-analysis was performed to explore the comparative efficacy and safety of dual (an antiplatelet plus an oral anticoagulant) versus triple therapy (dual antiplatelet therapy plus an oral anticoagulant). METHODS We searched the literature for randomized controlled trials (RCTs) or observational studies (OSs) addressing this issue. The efficacy outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction and stent thrombosis. The safety outcomes were major bleeding events and all bleeding events. The analyses were stratified by type of anticoagulant and of antiplatelet used in dual therapy. RESULTS Four RCTs and ten OSs met our inclusion criteria including a total of 10,126 patients. 5671 patients received triple therapy whereas 4455 received dual therapy. Median follow up was 12 months. There was no difference between dual therapy and triple therapy regarding efficacy outcomes. Dual therapy significantly reduced the risk of major bleeding (RR 0.66; CI 95% 0.52-0.83; P = 0.0005) and of all bleeding events (RR 0.67, CI 95% 0.55-0.80; P < 0.0001). The effect was consistent regardless of the type of antiplatelet and anticoagulant used in dual therapy. CONCLUSION Dual antithrombotic therapy after coronary stenting in anticoagulated patients significantly reduces bleeding events compared with triple therapy. Dual therapy might be considered in this setting especially when bleeding risk outweighs ischemic risk, although our study was not sufficiently powered to detect a difference in ischemic endpoints.
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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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Liu L, Huang J, Zhang X, Tang X. Efficacy and safety of triple therapy versus dual antiplatelet therapy in patients with atrial fibrillation undergoing coronary stenting: A meta-analysis. PLoS One 2018; 13:e0199232. [PMID: 29920547 PMCID: PMC6007837 DOI: 10.1371/journal.pone.0199232] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 06/04/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The optimal antithrombotic therapy for atrial fibrillation (AF) patients undergoing coronary stenting is unknown. The present meta-analysis sought to investigate the efficacy and safety of triple therapy (TT; warfarin, clopidogrel and aspirin) vs dual antiplatelet therapy (DAPT; clopidogrel plus aspirin) in those patients. METHODS PubMed and Cochrane Library were searched for studies enrolling AF patients undergoing coronary stenting on TT and DAPT up to September 2016, and fourteen studies were included. Efficacy outcomes included ischemic stroke, stent thrombosis, major adverse cardiovascular event (MACE), all-cause mortality and myocardial infarction (MI); safety outcome was major bleeding. We conducted meta-analysis and used odds ratio (OR) with 95% confidence intervals (CI) to compare TT and DAPT. Meta-regression, sensitivity and subgroup analysis were taken to investigate the source of heterogeneity in the outcome of major bleeding. RESULTS 14 eligible observational studies with 11,697 subjects were identified. Compared with DAPT, TT had decreased the risk of ischemic stroke [OR = 0.74, 95% CI (0.59, 0.93), P = 0.009] and stent thrombosis [OR = 0.40, 95% CI (0.18, 0.93), P = 0.033]. While, there was an increased risk of major bleeding [OR = 1.55, 95% CI (1.16, 2.09), P = 0.004] associated with TT. The risk of MACE, all-cause mortality and MI had no significant statistical difference between TT and DAPT. Furthermore, the results of univariate and multivariate meta-regression analysis implicated that there were no obvious correlations between certain baseline characteristics (age, gender, race, hypertension, study design) and risk of major bleeding. Also of major bleeding, the findings of sensitivity analysis were generally robust, and a prespecified subgroup analysis of race demonstrated that the source of heterogeneity might attribute to Asian studies mostly. CONCLUSIONS TT reduced the risk of ischemic stroke and stent thrombosis with an acceptable major bleeding risk compared with DAPT, and TT was considered as a valid alternative in AF patients undergoing coronary stenting. Further prospective randomized trials are needed to ensure the reliability of these data and find the optimal therapeutic strategy in this setting of patients.
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Affiliation(s)
- Liyao Liu
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Jietao Huang
- Department of Cardiology, Chongqing Emergency Medical Center, Chongqing, P. R. China
| | - Xiaogang Zhang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Xiaoman Tang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
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Antithrombotic therapy strategies for atrial fibrillation patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis. PLoS One 2017; 12:e0186449. [PMID: 29023526 PMCID: PMC5638551 DOI: 10.1371/journal.pone.0186449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/15/2017] [Indexed: 11/30/2022] Open
Abstract
Objective The aim of this systematic review and network meta-analysis was to evaluate the comparative efficacy and safety of antiplatelet agents, vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). Methods PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify clinical trials comparing antiplatelet drugs with VKA and NOACs or their combination in AF patients undergoing PCI with a mean/median follow-up of at least 12 months. A network meta-analysis was conducted to directly and indirectly compare the efficacy and safety of competitive antithrombotic regimens with a Bayesian random-effects model. Results were presented as relative risks (RRs) and 95% confidence intervals (CIs). Results A total of 15 studies enrolling 13,104 patients were included. Among 5 regimens, rivaroxaban 15 mg daily plus P2Y12 inhibitor treatment demonstrated significant superiority over dual- and triple-antiplatelet therapies (DAPT, TT) in reducing thromboembolic events (0.64 [0.38, 0.95] and 0.68 [0.43, 0.98], respectively) but showed the maximum possibility of major bleeding risk, while VKA plus single antiplatelet therapy (SAPT) seemed the safest. Significantly less risk of major bleeding was seen in DAPT group than that in TT group (0.63 [0.39, 0.99]). Conclusions The present study suggests that combination of VKA and SAPT is the best choice for AF patients undergoing PCI considering both efficacy and safety. Rivaroxaban 2.5 mg twice daily plus DAPT treatment owns the highest probability to be the optimal alternative to VKA plus SAPT for these patients.
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12
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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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Kubo T, Ino Y, Matsuo Y, Shiono Y, Kameyama T, Yamano T, Katayama Y, Taruya A, Nishiguchi T, Satogami K, Kashiyama K, Orii M, Kuroi A, Yamaguchi T, Tanaka A, Hozumi T, Akasaka T. Reduction of in-stent thrombus immediately after percutaneous coronary intervention by pretreatment with prasugrel compared with clopidogrel: An optical coherence tomography study. J Cardiol 2017; 69:436-441. [DOI: 10.1016/j.jjcc.2016.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 03/30/2016] [Accepted: 04/09/2016] [Indexed: 10/21/2022]
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Chaudhary N, Bundhun PK, Yan H. Comparing the clinical outcomes in patients with atrial fibrillation receiving dual antiplatelet therapy and patients receiving an addition of an anticoagulant after coronary stent implantation: A systematic review and meta-analysis of observational studies. Medicine (Baltimore) 2016; 95:e5581. [PMID: 27977592 PMCID: PMC5268038 DOI: 10.1097/md.0000000000005581] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Data regarding the clinical outcomes in patients with atrial fibrillation (AF) receiving dual antiplatelet therapy (DAPT) and an anticoagulant in addition to DAPT (DAPT + vitamin K antagonist [VKA]) after coronary stent implantation are still controversial. Therefore, in order to solve this issue, we aim to compare the adverse clinical outcomes in AF patients receiving DAPT and DAPT + VKA after percutaneous coronary intervention and stenting (PCI-S). METHODS Observational studies comparing the adverse clinical outcomes such as major bleeding, major adverse cardiovascular events, stroke, myocardial infarction, all-cause mortality, and stent thrombosis (ST) in AF patients receiving DAPT + VKA therapy, and DAPT after PCI-S have been searched from Medline, EMBASE, and PubMed databases. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on discontinuous variables, and the pooled analyses were performed with RevMan 5.3. RESULTS Eighteen studies consisting of a total of 20,456 patients with AF (7203 patients received DAPT + VKA and 13,253 patients received DAPT after PCI-S) were included in this meta-analysis. At a mean follow-up period of 15 months, the risk of major bleeding was significantly higher in DAPT + VKA group, with OR 0.62 (95% CI 0.50-0.77, P < 0.0001). There was no significant differences in myocardial infarction and major adverse cardiovascular event between DAPT + VKA and DAPT, with OR 1.27 (95% CI 0.92-1.77, P = 0.15) and OR 1.17 (95% CI 0.99-1.39, P = 0.07), respectively. However, the ST, stroke, and all-cause mortality were significantly lower in the DAPT + VKA group, with OR 1.98 (95% CI 1.03-3.81, P = 0.04), 1.59 (95% CI 1.08-2.34, P = 0.02), and 1.41 (95% CI 1.03-1.94, P = 0.03), respectively. CONCLUSION At a mean follow-up period of 15 months, DAPT + VKA was associated with significantly lower risk of stroke, ST, and all-cause mortality in AF patients after PCI-S compared with DAPT group. However, the risk of major bleeding was significantly higher in the DAPT + VKA group.
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Hoshi T, Sato A, Nogami A, Gosho M, Aonuma K. Rationale and design of the SAFE-A study: SAFety and Effectiveness trial of Apixaban use in association with dual antiplatelet therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. J Cardiol 2016; 69:648-651. [PMID: 27443596 DOI: 10.1016/j.jjcc.2016.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/09/2016] [Accepted: 06/20/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with atrial fibrillation who undergo coronary stenting require triple antithrombotic therapy, including aspirin, a P2Y12 inhibitor, and anticoagulation, to prevent both stroke and stent thrombosis. However, triple therapy may increase the risk of bleeding complications. The optimal management of triple therapy still presents a challenge in these patients. HYPOTHESIS We hypothesized that 1-month P2Y12 inhibitor treatment after drug-eluting stent (DES) implantation, as compared with 6-month P2Y12 inhibitor treatment, in combination with aspirin and apixaban, would be associated with a decrease in the incidence of bleeding complications in patients with atrial fibrillation who undergo DES implantation. DESIGN SAFE-A (UMIN Clinical Trials Registry Number: UMIN000015923) is a multicenter, prospective, randomized, open-label, blinded-endpoint, parallel-group, comparative study that was designed to compare the safety and efficacy of short-duration treatment with a P2Y12 inhibitor in combination with aspirin and apixaban in subjects with non-valvular atrial fibrillation who undergo DES implantation. A total of 600 subjects will be randomized in a 1:1 fashion to either 1-month or 6-month P2Y12 inhibitor therapy in combination with aspirin and apixaban. The primary endpoint is the incidence of all bleeding complications occurring within 12 months. CONCLUSION The SAFE-A study is the first randomized controlled trial to compare 1-month vs. 6-month P2Y12 inhibitor therapy in combination with aspirin and apixaban, in patients with atrial fibrillation who undergo DES implantation. This study will provide data that may guide the optimal management of triple antithrombotic therapy.
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Affiliation(s)
- Tomoya Hoshi
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Akira Sato
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Akihiko Nogami
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masahiko Gosho
- Department of Clinical Trial and Clinical Epidemiology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kazutaka Aonuma
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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Impact of preoperative dual antiplatelet therapy on bleeding complications in patients with acute coronary syndromes who undergo urgent coronary artery bypass grafting. J Cardiol 2016; 69:156-161. [PMID: 26987791 DOI: 10.1016/j.jjcc.2016.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/05/2016] [Accepted: 02/12/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND A 5- to 7-day washout period before coronary artery bypass grafting (CABG) is recommended for patients who have recently received a thienopyridine derivative; however, data supporting this guideline recommendation are lacking in Japanese patients. METHODS Urgent isolated CABG was performed in 130 consecutive patients with acute coronary syndromes (ACS) (101 men; mean age, 69 years). Urgent CABG was defined as operation performed within 5 days after coronary angiography. All patients continued to receive aspirin 100mg/day. The subjects were retrospectively divided into 2 groups: 30 patients with preoperative thienopyridine (clopidogrel in 15 patients, ticlopidine in 15) exposure within 5 days [dual antiplatelet therapy (DAPT) group] and 100 patients without exposure [single antiplatelet therapy (SAPT) group]. RESULTS Although the DAPT group had a higher proportion of patients who received perioperative platelet transfusions than the SAPT group (50% vs. 18%, p<0.001), intraoperative bleeding (median, 1100ml; interquartile range, 620-1440 vs. 920ml; 500-1100) and total drain output within 48h after surgery (577±262 vs. 543±277ml) were similar. CABG-related major bleeding, which was defined as type 4 or 5 bleeding according to the Bleeding Academic Research Consortium definitions, occurred in a significantly higher proportion of patients in the DAPT group than in the SAPT group (20% vs. 3%, p=0.005). This difference in major bleeding was driven mainly by the higher rate of transfusion of ≥5U red blood cells within a 48-h period in the DAPT group (13% vs. 1%, p=0.01). There was no significant difference in the 30-day composite endpoint including death, myocardial (re)infarction, ischemic stroke, and refractory angina between the DAPT group and SAPT group (17% vs. 19%). CONCLUSIONS Preoperative DAPT increases the risk of CABG-related major bleeding in Japanese patients with ACS undergoing urgent CABG.
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Nishino M, Okamoto N, Tanaka A, Mori N, Hara M, Yano M, Makino N, Egami Y, Shutta R, Tanouchi J. Different risk factors for bleeding and discontinuation between dabigatran and rivaroxaban. J Cardiol 2015; 68:156-60. [PMID: 26443373 DOI: 10.1016/j.jjcc.2015.08.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/18/2015] [Accepted: 08/31/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is unclear whether risk factors for bleeding and discontinuation are different between dabigatran and rivaroxaban. METHODS AND RESULTS We enrolled consecutive patients with atrial fibrillation who received dabigatran or rivaroxaban, had a CHADS2 score >1 and creatinine clearance >30ml/min. During this period, only dabigatran and rivaroxaban were available as non-vitamin K oral anticoagulants (NOACs) in our hospital. We compared the clinical and demographic data and the incidence of bleeding for one year between dabigatran group and rivaroxaban group. As a result, the dabigatran group consisted of 177 patients and the rivaroxaban group consisted of 179 patients. The incidence of discontinuation was significantly higher in the dabigatran group than in the rivaroxaban group (27.7% vs. 13.4%, p<0.001). Multivariate analysis, even after propensity score-matching analysis, revealed that there were no independent risk factors for bleeding in the dabigatran group, while in the rivaroxaban group, use of antiplatelet therapy was an independent factor correlating with bleeding. CONCLUSIONS The risk factors for bleeding may be different between dabigatran and rivaroxaban. To avoid bleeding, rivaroxaban should be prescribed with caution or avoided in patients using antiplatelet therapy. Upon discontinuation, rivaroxaban may be more favorable than dabigatran.
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Affiliation(s)
- Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan.
| | - Naotaka Okamoto
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Akihiro Tanaka
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Naoki Mori
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Masahiko Hara
- Department of Cardiovascular Medicine and Medical Innovation, Osaka University Hospital, Suita, Osaka, Japan
| | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Nobuhiko Makino
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Ryu Shutta
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Jun Tanouchi
- Division of Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
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