2
|
Omission of aspirin in patients taking oral anticoagulation after percutaneous coronary intervention: a systematic review and meta-analysis. Coron Artery Dis 2020; 30:109-115. [PMID: 30629002 DOI: 10.1097/mca.0000000000000698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is no consensus on optimal antiplatelet and anticoagulation therapy after coronary stenting. METHODS We identified randomized controlled trials (RCTs) published in PubMed, Cochrane Library, and Embase using the following keywords: 'antiplatelet', 'dual therapy', 'triple therapy', 'antithrombosis', 'indication for anticoagulation', 'percutaneous coronary intervention', and 'RCTs'. Primary safety end points were relative bleeding events, and secondary efficacy end points were major adverse cardiovascular events including stent thrombosis, death, myocardial infarction, and stroke. RESULTS We identified three RCTs including 5387 patients, of whom 2719 (50.5%) received dual therapy (DT) and 2668 (49.5%) received triple therapy. Relative to triple therapy, DT was associated with lower Thrombolysis in Myocardial Infarction major bleeding [risk ratio (RR): 0.58; 95% confidence interval (CI): 0.42-0.82], Thrombolysis in Myocardial Infarction minor bleeding (RR: 0.46; 95% CI: 0.34-0.62), and clinical bleeding events (RR: 0.61; 95% CI: 0.47-0.81). There was no significant difference for the secondary efficacy end point. In subgroup analyses, results were similar by sex, bleeding risk, and stent type; however, DT appeared suitable for patients aged less than 75 years but not more than or equal to 75 years, implying that there may be no ideal therapy for patients older than 75 years to balance the risk of ischemia and bleeding at the same time. CONCLUSION Among patients with an indication for oral anticoagulation after percutaneous coronary intervention, DT appears to be the optimal strategy.
Collapse
|
3
|
Kirolos I, Ifedili I, Maturana M, Premji AM, Cave B, Roman S, Jones D, Gaid R, Levine YC, Jha S, Kabra R, Khouzam RN. Ticagrelor or prasugrel vs. clopidogrel in combination with anticoagulation for treatment of acute coronary syndrome in patients with atrial fibrillation. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:406. [PMID: 31660305 DOI: 10.21037/atm.2019.07.41] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
For patients with atrial fibrillation (AF) and acute coronary syndrome (ACS), it is often challenging to find the optimal balance between the risk for ischemic and hemorrhagic complication when using both antiplatelet therapy and oral anticoagulation (OAC) with vitamin K antagonist (VKA) or direct oral anticoagulants (DOACs). Current guidelines recommended: (I) double therapy with a P2Y12 inhibitor and dose adjusted VKA is reasonable post-stenting; (II) double therapy with clopidogrel and low-dose rivaroxaban (15 mg daily) may be reasonable post-stenting; (III) double therapy with a P2Y12 inhibitor and dabigatran 150 mg twice daily is reasonable post-stenting. In the AUGUSTUS trial, most patients were given clopidogrel as part a DAPT regimen, however prasugrel and ticagrelor use allowed albeit in a small percentage of the trial population, underestimating its effect. Ticagrelor and prasugrel are known to have a stronger antiplatelet effect compared to clopidogrel, however randomized studies have not been adequately powered to date allowing comparisons between ticagrelor, prasugrel and clopidogrel together in the setting of anticoagulation for the treatment of patients with ACS and AF. Careful consideration should be given to this scenario to avoid falling into the concept of sacrificing efficacy for safety.
Collapse
Affiliation(s)
- Irene Kirolos
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Ikechukwu Ifedili
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Miguel Maturana
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Alykhan Moez Premji
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Brandon Cave
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Sherif Roman
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - David Jones
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Romany Gaid
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Yehoshua C Levine
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Sunil Jha
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Rajesh Kabra
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| | - Rami N Khouzam
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Cardiovascular Institute, Methodist Le Bonheur Healthcare System, Memphis TN, USA
| |
Collapse
|
4
|
D'Angelo RG, McGiness T, Waite LH. Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: Where Are We Now? Ann Pharmacother 2018; 52:884-897. [PMID: 29577768 DOI: 10.1177/1060028018766837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To synthesize the literature and provide guidance to practitioners regarding double therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) requiring percutaneous coronary intervention (PCI). DATA SOURCES PubMed and MEDLINE (January 2000 to February 2018) were searched using the following terms: atrial fibrillation, myocardial infarction, acute coronary syndrome, percutaneous coronary intervention, anticoagulation, dual-antiplatelet therapy, clopidogrel, aspirin, ticagrelor, prasugrel, and triple therapy. STUDY SELECTION AND DATA EXTRACTION The results included randomized and nonrandomized clinical trials and meta-analyses. Each study was reported based on study design, population, intervention, comparator, and key cardiovascular (CV) and bleeding outcomes. DATA SYNTHESIS A total of 15 studies were included in the review. The majority of studies evaluating DT and TT utilized clopidogrel and warfarin as components of the regimen, although there are emerging data with newer agents. Evidence purporting DT regimens to be equally effective in preventing CV events and improved safety profiles compared with TT regimens included populations with relatively low risk for recurrent CV events, and many of these studies were observational in nature. Overall, current evidence as well as American and European guidelines support the use of TT in patients with AF who require PCI for the least possible amount of time, depending on patient-specific factors involving bleeding and thrombosis. CONCLUSIONS In the majority of patients with AF who require PCI, TT should be used for the shortest period of time possible. DT regimens may be used in patients requiring PCI who have low risk for thrombosis and/or high bleeding risk.
Collapse
Affiliation(s)
- Ryan G D'Angelo
- 1 University of the Sciences-Philadelphia College of Pharmacy, Philadelphia, PA, USA.,2 Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Thaddeus McGiness
- 1 University of the Sciences-Philadelphia College of Pharmacy, Philadelphia, PA, USA.,2 Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Laura H Waite
- 1 University of the Sciences-Philadelphia College of Pharmacy, Philadelphia, PA, USA.,2 Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
5
|
Raschi E, Bianchin M, Fantoni C, Ageno W, De Ponti F, De Ponti R. Evolving cardiovascular uses of direct-acting oral anticoagulants: a paradigm shift on the horizon? Intern Emerg Med 2017; 12:923-934. [PMID: 28785902 DOI: 10.1007/s11739-017-1724-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/29/2017] [Indexed: 12/27/2022]
Abstract
Direct-acting oral anticoagulants (DOACs), by virtue of pharmacological properties perceived as innovative, are changing the therapeutic scenario of patients requiring short- and long-term anticoagulation. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirms that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy, effectiveness and unequivocally documents a clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (AF) and venous thromboembolism. The following issues are attracting considerable clinical interest: (a) identifying specific subpopulations of patients with AF most likely to benefit from one of these agents (the so-called tailored therapy), and (b) expanding therapeutic indications in emerging diseases characterized by arterial and venous thromboembolic risk. In these scenarios, the risk-benefit profile of DOACs, as compared to VKAs or heparins, is still incompletely characterized. In cardiology, the challenging task of selecting a suitable or even the most appropriate DOAC for patients with AF and a particular phenotype prompted experts to provide suggestions based on careful review of subgroups of patients from pivotal RCTs. However, in the past few months, variegated multicenter trials have been published (RE-CIRCUIT, PIONEER-AF-PCI, GEMINI-ACS-1), with potential influence on clinical practice. Therefore, this review aims to update the latest evidence on the evolving therapeutic uses of DOACs in the cardiovascular area, addressing potential impact for clinicians.
Collapse
Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy
| | - Cecilia Fantoni
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy.
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| |
Collapse
|