Anticoagulation plus aspirin following acute myocardial infarction: yes or no ... and if the latter, why not?

Dilemma of antithrombotic therapy in anticoagulated atrial fibrillation patients squeezed between thrombosis and bleeding events: a single-centre experience

The aim of this study was to evaluate the rate of bleeding, thromboembolic complications, and the rate of stent thrombosis or restenosis in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). In this retrospective analysis, we included patients with AF who underwent PCI with stent implantation from 2003 to 2006. Combinations of aspirin, clopidogrel, and oral anticoagulation with phenprocoumon (OAC) were used for antithrombotic management. Follow-up was performed by telephone interview. Adverse events (AEs) were defined as major bleedings, stroke/transient ischaemic attack, peripheral embolism, stent thrombosis, or restenosis. One hundred and seventeen patients (85 men, mean age 72.0 +/- 8.2 years) were included in the study. Fifty-five patients (47%) received drug-eluting stents, 62 patients (53%) bare-metal stents. After coronary intervention, 53 patients (45.3%) received a combination of aspirin, clopidogrel, and OAC, 64 (54.7%) patients received other antithrombotic regimens. Eighteen patients died during follow-up, 11 patients presumably of cardiac and 7 patients of non-cardiac causes. In total, 26 AEs occurred in 24 of 113 patients (21.2%) during follow-up: 13 major bleedings, 6 cardioembolic complications, 3 stent thromboses, and 4 restenoses. The present study demonstrates an 11.5% rate of major bleedings, a 5.3% rate of thromboembolic events, and a 2.7% rate of stent thromboses in the high-risk group of patients with AF and coronary stent implantation. The decision on different antithrombotic treatment regimens needs to be based on the patients' individual risk until further prospective studies have evaluated the risk-benefit profile of a standardized approach of triple therapy in this high-risk patient group.

Anticoagulant and Antiplatelet Therapy Use in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

BACKGROUND

There is a lack of published evidence on what is the optimal management strategy in anticoagulated patients with nonvalvular atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) and, hence, need antiplatelet therapy.

AIMS

Review of cases of patients with nonvalvular AF undergoing PCI in our hospital, either as an elective case or following acute coronary syndrome (ACS).

METHODS

By means of our local West Midlands Regional Health Authority computerized Hospital Activity Analysis register, we obtained a list of all patients seen at our hospital with a diagnosis of AF in association with ACS or PCI between 2000 and 2005. Patient clinical details and antithrombotic therapy management during PCI were recorded.

RESULTS

Of the drugs prescribed on discharge, aspirin and clopidogrel were prescribed to 25 patients (71.4%), while 6 patients (17.1%) were discharged receiving triple therapy, 2 patients (5.7%) receiving clopidogrel alone, and 2 patients (5.7%) receiving warfarin plus one antiplatelet drug (either aspirin or clopidogrel). There was wide variability in the antithrombotic regime and duration of treatment used by the four interventionists in our unit.

CONCLUSION

This case series reveals the lack of any coordinated strategy in the prevention of thrombotic or thromboembolic events in patients with AF and a recent PCI. Further large studies are required to assess the bleeding and thrombotic risk with various post-PCI strategies in order to facilitate the development of guidelines. Suggested management guidelines are made in this article.