Antithrombotic management of patients with acute coronary syndrome and atrial fibrillation undergoing coronary stenting: a prospective, observational, nationwide study

Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios

It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.

Changes in Antithrombotic Therapy Prescription in Patients with a Combination of Atrial Fibrillation and Myocardial Infarction in a Specialised Inpatient Department from 2016-2019 and Associations with Prognosis

Background and Objectives: The problem of treating patients with atrial fibrillation and myocardial infarction is relevant. The issue of optimal antithrombotic therapy in these patients has not been definitively resolved. This work analyzes the influence of clinical factors and treatment on the long-term prognosis of patients. Materials and Methods: The research included 360 patients with atrial fibrillation and myocardial infarction during 2016-2019. Results: The factors associated with fatal outcomes were age (hazard ratio (HR): 1.05; 95% confidence interval (CI): 1.03-1.07; p < 0.001); stroke (HR: 1.95; 95% CI: 1.27-3.00; p = 0.0002); glomerular filtration rate (HR: 0.988; 95% CI: 0.978-0.998; p = 0.03); left ventricular ejection fraction (HR: 0.975; 95% CI: 0.957-0.999; p = 0.007); and aspirin (HR: 0.48; 95% CI: 0.31-0.73; p < 0.001). The factors associated with the combined endpoint were chronic kidney disease (HR: 1.46; 95% CI: 1.01-2.10; p = 0.04); HAS-BLED (HR: 1.23; 95% CI: 1.06-1.43; p = 0.007); percutaneous coronary intervention (HR: 0.70; 95% CI: 0.51-0.96; p = 0.03); and aspirin (HR: 0.65; 95% CI: 0.44-0.97; p = 0.03). Conclusions: Double and triple antithrombotic therapy were not associated with outcomes. Aspirin improved the prognosis for survival and the combined endpoint.

ANMCO-SIMEU consensus document: appropriate management of atrial fibrillation in the emergency department

Atrial fibrillation (AF) accounts for 2% of the total presentations to the emergency department (ED) and represents the most frequent arrhythmic cause for hospitalization. It steadily increases the risk of thromboembolic events and is often associated with several comorbidities that negatively affect patient's quality of life and prognosis. AF has a considerable impact on healthcare resources, making the promotion of an adequate and coordinated management of this arrhythmia necessary in order to avoid clinical complications and to implement the adoption of appropriate technological and pharmacological treatment options. AF management varies across regions and hospitals and there is also heterogeneity in the use of anticoagulation and electric cardioversion, with limited use of direct oral anticoagulants. The ED represents the first access point for early management of patients with AF. The appropriate management of this arrhythmia in the acute setting has a great impact on improving patient's quality of life and outcomes as well as on rationalization of the financial resources related to the clinical course of AF. Therefore, physicians should provide a well-structured clinical and diagnostic pathway for patients with AF who are admitted to the ED. This should be based on a tight and propositional collaboration among several specialists, i.e. the ED physician, cardiologist, internal medicine physician, anesthesiologist. The aim of this ANMCO-SIMEU consensus document is to provide shared recommendations for promoting an integrated, accurate, and up-to-date management of patients with AF admitted to the ED or Cardiology Department, in order to make it homogeneous across the national territory.

Dual antithrombotic therapy and gastroprotection in atrial fibrillation: an observational primary care study

BACKGROUND

Patients with both atrial fibrillation (AF) and cardiovascular disease (CVD) may receive dual antithrombotic therapy (DAT) with both an anticoagulant and ≥1 antiplatelet agents. Avoiding prolonged duration of DAT and use of gastroprotective therapies reduces bleeding risk.

AIM

To describe the extent and duration of DAT and use of gastroprotection in a primary care cohort of patients with AF.

DESIGN & SETTING

Observational study in 1.2 million people registered with GPs across four east London clinical commissioning groups (CCGs), covering prescribing from January 2020-June 2021.

METHOD

In patients with AF, factors associated with DAT prescription, prolonged DAT prescription (>12 months), and gastroprotective prescription were characterised using logistic regression.

RESULTS

There were 8881 patients with AF, of whom 4.7% (n = 416) were on DAT. Of these, 65.9% (n = 274) were prescribed DAT for >12 months and 84.4% (n = 351) were prescribed concomitant gastroprotection. Independent of all other factors, females with AF were less likely to receive DAT than males (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.49 to 0.77). Similarly, older (aged ≥75 years) individuals (OR 0.79, 95% CI = 0.63 to 0.98) were less likely to receive DAT than younger patients. Among those with AF on DAT, pre-existing CVD (OR 3.33, 95% CI = 1.71 to 6.47) and South Asian ethnicity (OR 2.70, 95% CI = 1.15 to 6.32) were associated with increased gastroprotection prescriptions. Gastroprotection prescription (OR 1.80, 95% CI = 1.01 to 3.22) was associated with prolonged DAT prescription.

CONCLUSION

Almost two-thirds of patients with AF on DAT were prescribed prolonged durations of therapy. Prescription of gastroprotection therapies was suboptimal in one in six patients. Treatment decisions varied by sex, age, ethnic group, and comorbidity. Duration of DAT and gastroprotection in patients with AF requires improvement.

ANMCO position paper on antithrombotic treatment of patients with atrial fibrillation undergoing intracoronary stenting and/or acute coronary syndromes

Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with or without acute coronary syndromes (ACS) represent a subgroup with a challenging pharmacological management. Indeed, if on the one hand, antithrombotic therapy should reduce the risk related to recurrent ischaemic events and/or stent thrombosis; on the other hand, care must be taken to avoid major bleeding events. In recent years, several trials, which overall included more than 12 000 patients, have been conducted demonstrating the safety of different therapeutic combinations of oral antiplatelet and anticoagulant agents. In the present ANMCO position paper, we propose a decision-making algorithm on antithrombotic strategies based on scientific evidence and expert consensus to be adopted in the periprocedural phase, at the time of hospital discharge, and in the long-term follow-up of patients with AF undergoing PCI with/without ACS.

Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention

Patients with atrial fibrillation (AF) are at increased risk for coronary artery disease (CAD). After percutaneous coronary intervention (PCI), the antithrombotic therapy consists of a combination of anticoagulant and antiplatelet agents to reduce the ischemic and thromboembolic risk, at the cost of increased bleeding events. In the past few years, several randomized clinical trials involving over 12,000 patients have been conducted to compare the safety of vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs) in association with a single- or double-antiplatelet agent, in the so-called dual- (DAT) or triple-antithrombotic therapy (TAT). These studies and several meta-analyses showed a consistent benefit for reducing bleeding events of DAT over TAT and of DOAC over VKA, without concerns about ischemic endpoints, except for a trend for increased stent thrombosis risk. The present paper examines current international guidelines’ recommendations and reviews clinical trials, meta-analyses, and observational studies conducted on AF patients treated with DAT or TAT after PCI for acute coronary syndromes.

The role of triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention

Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel forms the backbone of secondary prevention in patients with acute coronary syndromes (ACS) or who undergo percutaneous coronary intervention (PCI), but in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is superior to antiplatelet therapy for the prevention of stroke and systemic embolism. Patients with AF who undergo PCI or have an ACS event therefore have an indication for both OAC and DAPT, so-called triple antithrombotic therapy. However, observational analyses have shown that the annual rate of major bleeding on triple therapy exceeds 10%. For this reason, five major randomized clinical trials have compared double antithrombotic therapy with OAC and a P2Y₁₂ inhibitor versus triple therapy in patients with AF who underwent PCI or had an ACS event. Each of the trials showed that double antithrombotic therapy reduced the rate of major and clinically relevant non-major bleeding compared with triple therapy and was non-inferior for prevention of ischemic events, including cardiovascular death, myocardial infarction, or stroke. In the one trial that directly compared warfarin with a non-vitamin K antagonist oral anticoagulant (NOAC), apixaban reduced the rate of major or clinically relevant non-major bleeding compared with warfarin and was non-inferior with respect to prevention of ischemic events. As a result of these trials, consensus guidelines recommend that patients with AF who undergo PCI or have an ACS event should be treated with triple antithrombotic therapy (OAC + P2Y₁₂ inhibitor + aspirin) for 7 days or less, followed by double antithrombotic therapy (OAC + P2Y₁₂ inhibitor) for 6 to 12 months.

Antithrombotic strategy and its relationship with outcomes in patients with atrial fibrillation and chronic coronary syndrome

This study aimed to explore antithrombotic strategy and its relationship with outcomes in patients with atrial fibrillation (AF) at high risk for stroke and chronic coronary syndrome (CCS) in real-world clinical practice. Patients with AF at high risk for stroke complicated with CCS from China Atrial Fibrillation Registry (CAFR) were enrolled. The patients were divided into non-antithrombotic (Non-AT) group, oral anticoagulants (OAC) group, antiplatelet therapy (APT) group (aspirin or clopidogrel), and dual antiplatelet therapy (DAPT) group (aspirin + clopidogrel) according to their antithrombotic strategies at baseline. The patients with OAC + single antiplatelet drug (14 cases) and OAC + dual antiplatelet therapy (7 cases) were excluded for the small sample size. The primary effectiveness outcome was the composite outcome of coronary events, thromboembolism, and all-cause mortality. The primary safety outcome was major bleeding events. From 2011 to 2018, 25,512 patients were included in the CARF study, 769 patients with AF at high risk for stroke and CCS were enrolled in this study. After a follow-up of 47.4 ± 25.3 months, the incidences of primary effectiveness outcome were 44.6%, 25.7%, 43.6%, and 29.1% in the four groups, respectively (P < 0.001). The incidences of primary effectiveness and all-cause mortality were both significantly lower in the OAC group than in the Non-AT group, (25.7% vs. 44.6%, HR 0.53, 95% CI 0.39-0.73, P < 0.001) and (14.6% vs. 38.5%, HR 0.36, 95%CI 0.25-0.52, P < 0.001). In multivariate analysis, age (HR 1.03, 95%CI 1.01-1.05, P = 0.015), heart failure (HR 1.67, 95%CI 1.20-2.33, P = 0.002) and OAC (HR 0.66, 95%CI 0.47-0.91, P = 0.012) were independent factors for the composite outcome. There was no significant difference in major bleeding events between the four groups. OAC monotherapy significantly reduced the primary effectiveness composite outcome and all-cause mortality in the patients with AF at high risk for stroke complicated with CCS. However, there was no significant difference in major bleeding among the different antithrombotic strategies.Trial Registration www.chictr.org.cn (No. ChiCTR-OCH-13003729).

Is percutaneous coronary intervention safe during uninterrupted direct oral anticoagulant therapy in patients with atrial fibrillation and acute coronary syndromes?

Objectives

No data on optimal management of patients with acute coronary syndromes (ACS) on long-term direct oral anticoagulants (DOACs) undergoing percutaneous coronary intervention (PCI) are available. Using the data of the Management of Antithrombotic TherApy in Patients with Chronic or DevelOping AtRial Fibrillation During Hospitalization for PCI study, we sought to compare the outcome of patients with ACS and atrial fibrillation (AF) who underwent PCI during uninterrupted DOAC (UDOAC group) and those who interrupted DOAC before PCI (IDOAC group).

Methods

The primary outcomes of our analysis were the incidence of major adverse cardiovascular events (MACEs), a composite of death, cerebrovascular events, recurrent myocardial infarction or revascularisation and net adverse clinical events (NACEs), including major bleeding, at 6 months.

Results

Among the 132 patients on long-term DOAC, 72 (54.6%) underwent PCI during UDOAC and 60 (45.4%) after IDOAC. The mean CHA₂DS₂-VASc score was 3.8±1.7 and 3.9±1.3 (p=0.89), while the HAS-BLED score was 2.5±1.0 and 2.5±0.9 (p=0.96), in UDOAC and IDOAC groups, respectively. The median time from hospital admission to PCI was 9.5 (IQR: 2.0–31.5) hours in UDOAC and 45.5 (IQR: 22-5–92.0) hours in IDOAC group (p<0.0001). A radial approach was used in 92%, and a drug-eluting stent was implanted in 98% of patients. At 6 months, the rates of MACE (13.9% vs 16.7%) and NACE (20.8% vs 21.7%) did not differ between UDOAC and IDOAC groups. At multivariable analysis, increasing CHA₂DS₂-VASc score (HR: 1.39; 95% CIs 1.05 to 1.83; p=0.02) resulted as the only independent predictor of NACE.

Conclusions

Our study shows that PCI is a safe procedure during UDOAC in patients with concomitant ACS and AF.

Post-discharge antithrombotic management and clinical outcomes of patients with new-onset or pre-existing atrial fibrillation and acute coronary syndromes undergoing coronary stenting: Follow-up data of the MATADOR-PCI study

BACKGROUND

. Patients with concomitant atrial fibrillation (AF) and acute coronary syndromes (ACS) do not seem to receive proper antithrombotic therapies and present high rates of adverse clinical events.

METHODS

. We analyzed the follow-up data of the prospective, nationwide MATADOR-PCI registry. We assessed the use of antithrombotic strategies and the incidence of major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) at 6 months, in patients with new-onset or pre-existing AF admitted for ACS and treated with percutaneous coronary intervention (PCI).

RESULTS

. Out of the 588 patients enrolled in the registry and discharged alive (287 with pre-existing and 301 with new-onset AF), data at 6 months were obtained for 579 (98.5%) patients. Compared to hospital discharge, the rate of triple antithrombotic therapy was significantly reduced (from 76.4% to 23.6% and from 53.8% to 23.6%; both p<0.0001) while dual antithrombotic therapy (DAT) increased (from 11.8% to 56.3% and from 5.8% to 30.9%; both p<0.0001) at follow-up, in patients with pre-existing and new-onset AF, respectively. Among patients with a class IA indication to receive oral anticoagulation therapy (OAT), it was prescribed in 91% and 88% of patients with pre-existing and 64% and 62% of new-onset AF, at discharge and follow-up, respectively. At 6 months from discharge the overall rate of MACE was 8.4% and 7.6% (p=0.75), while NACE occurred in 10.8% vs 10.0% (p=0.74) of patients with pre-existing or new-onset AF, respectively.

CONCLUSIONS

. At follow-up, DAT was the most used antithrombotic strategy for both patients with pre-existing and new-onset AF with concomitant ACS. These two groups of patients presented comparable rates of MACE and NACE at 6 months.