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Erbay MI, Pyrpyris N, Susarla S, Ulusan S, Mares AC, Wilson TP, Lee D, Sood A, Gupta R. Comparative safety review of antithrombotic treatment options for patients with atrial fibrillation undergoing percutaneous coronary intervention. Expert Opin Drug Saf 2024; 23:149-160. [PMID: 38214282 DOI: 10.1080/14740338.2024.2305367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/10/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Balancing antithrombotic therapy for atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI) remains a clinical challenge due to coexisting thrombogenic risks. This review emphasizes the delicate balance required to prevent ischemic events while minimizing bleeding complications, particularly in the context of risk assessment. AREAS COVERED This review spans from 2010 to October 2023, exploring the complexities of antithrombotic management for AF patients undergoing PCI. It stresses the need for personalized treatment decisions to optimize antithrombotic therapies effectively. EXPERT OPINION The evolving evidence supports double antithrombotic therapy (DAT) over triple antithrombotic therapy (TAT) for these patients, showcasing a more favorable safety profile without compromising efficacy. Non-vitamin K antagonist oral anticoagulant (NOAC)-based DAT strategies exhibit superiority in reducing major bleeding events while effectively preventing ischemic events. Recommendations from the 2023 European Society of Cardiology (ESC) Guidelines advocate for NOAC-based DAT post-PCI, endorsing safer antithrombotic profiles.Challenges persist for specific patient categories requiring both oral anticoagulants and antiplatelets, necessitating personalized approaches. Future advances in intravascular imaging and novel coronary stent technologies offer promising avenues to optimize outcomes and influence antithrombotic strategies in AF-PCI patients.
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Affiliation(s)
- Muhammed Ibrahim Erbay
- Division of Cardiovascular Medicine, Cerrahpasa School of Medicine, Istanbul University Cerrahpasa, Istanbul, Turkey
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Shriraj Susarla
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Sebahat Ulusan
- Faculty of Medicine, Suleyman Demirel University, Isparta, Isparta Province, Turkey
| | - Adriana C Mares
- Division of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven CT, USA
| | - Tasha Phillips Wilson
- Department of Internal Medicine, St. George's University School of Medicine, True Bule, Greneda
| | - Duo Lee
- Department of Cardiology, The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Aayushi Sood
- Department of Medicine, The Wright Center for Graduate Medical Education, Scranton, PA USA
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA USA
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Rowland B, Batty JA, Mehran R, Kunadian V. Triple Antiplatelet Therapy and Combinations with Oral Anticoagulants after Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Bai L, Yang XH, Zhou YQ, Cui XR, Fu LZ, Zhang JD. Safety and Efficacy Evaluation of Antithrombotic Therapy with Rivaroxaban and Clopidogrel After PCI in Chinese Patients. Clin Appl Thromb Hemost 2022; 28:10760296221074681. [PMID: 35200040 PMCID: PMC8883290 DOI: 10.1177/10760296221074681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the efficacy and safety of the antithrombotic therapy using the oral anticoagulant rivaroxaban and clopidogrel in Chinese patients with acute coronary syndrome complicated with atrial fibrillation after percutaneous coronary intervention. Methods A total of 100 patients were selected. Patients were randomly divided into two groups: the treatment group (rivaroxaban group) received a therapy of rivaroxaban and clopidogrel. The control group (warfarin group) receivied a combined treatment of warfarin, clopidogrel, and aspirin. The primary outcome endpoint was evaluated based on the adverse cardiac and cerebrovascular events within 12 months. Results A total of 8 (8.00%) main adverse cardiac and cerebrovascular events occurred during the 12 months of follow-up, including 5 (9.80%) in the warfarin group and 3 (6.10%) in the rivaroxaban group. The risk of having main adverse cardiac and cerebrovascular events in the two groups was comparable (P = 0.479). A total of 9 patients (9.00%) were found to have bleeding events, among which 8 patients (15.7%) were in the warfarin group, whereas only 1 patient (2.00%) was in the rivaroxaban group. Therefore, the risk of bleeding in the warfarin group was significantly higher than that in the rivaroxaban group (P = 0.047). Conclusions In Chinese patients with acute coronary syndrome complicated with atrial fibrillation, the efficacy of the dual therapy of oral anticoagulant rivaroxaban plus clopidogrel after percutaneous coronary intervention was similar to that of the traditional triple therapy combined with warfarin, aspirin and clopidogrel, but it has a better safety property, which has potential to widely apply to antithrombotic therapy after PCI
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Affiliation(s)
- Long Bai
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiao-Hong Yang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ya-Qing Zhou
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiao-Ran Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ling-Zhi Fu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ji-Dong Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. J Clin Med 2022; 11:jcm11030512. [PMID: 35159964 PMCID: PMC8836736 DOI: 10.3390/jcm11030512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Dawwas GK, Barnes GD, Dietrich E, Cuker A, Leonard CE, Genuardi MV, Lewis JD. Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis. Am Heart J 2021; 242:71-81. [PMID: 34450051 DOI: 10.1016/j.ahj.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF). OBJECTIVE To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF. DESIGN Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019. PARTICIPANTS New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis. MEASUREMENTS Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time. RESULTS After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72). LIMITATIONS Residual confounding. CONCLUSIONS In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.
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Bass ME, Kiser TH, Page RL, McIlvennan CK, Allen LA, Wright G, Shakowski C. Comparative effectiveness of direct oral anticoagulants and warfarin for the treatment of left ventricular thrombus. J Thromb Thrombolysis 2021; 52:517-522. [PMID: 33420896 DOI: 10.1007/s11239-020-02371-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/05/2023]
Abstract
Left ventricular (LV) thrombus is a complication of acute endomyocardial injury and chronic ventricular wall hypokinesis, resulting in increased risk of thromboembolic complications. Observational studies support the general safety and efficacy of warfarin for this indication. Limited data exists regarding the use of direct oral anticoagulants (DOACs) for LV thrombus. This retrospective cohort study sought to compare the incidence of thromboembolic events, bleeding rates, and blood product administration in patients receiving a DOAC versus warfarin. A total of 949 patients met inclusion, 180 (19%) received a DOAC and 769 (81%) warfarin. For the primary endpoint of new onset thromboembolic stroke, no difference existed between treatments (DOAC: 7.8% vs warfarin: 11.7%, p = 0.13). When compared to warfarin, no difference existed in the composite of thromboembolic events (33% vs 30.6%, p = 0.53, respectively) or in GUSTO bleeding (10.9% vs 7.8%, p = 0.40, respectively). More patients on warfarin received blood products compared to those taking a DOAC (25.8% vs 13.9%, p < 0.001).DOACs may be an alternative to warfarin for the treatment of LV thrombus based on a retrospective assessment of thromboembolic events and GUSTO bleeding events within 90 days of diagnosis of LV thrombus. However, further prospective studies are warranted.
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Affiliation(s)
- Megan E Bass
- Department of Pharmacy, UCHealth - University of Colorado Hospital, 12505 E. 16th Avenue, Aurora, CO, 80045, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Robert L Page
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Colleen K McIlvennan
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Larry A Allen
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Garth Wright
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Courtney Shakowski
- Department of Pharmacy, UCHealth - University of Colorado Hospital, 12505 E. 16th Avenue, Aurora, CO, 80045, USA.
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Kerley RN, Fitzgerald G, Coughlan JJ, Kelly C, Waters M, Reynolds A, Mulcahy D, Moore DP, Loo B, Curtin R. Real World Prescribing Strategies for Patients With an Indication for Oral Anticoagulation Undergoing Percutaneous Coronary Intervention. J Cardiovasc Pharmacol Ther 2020; 26:67-74. [PMID: 32783474 DOI: 10.1177/1074248420947280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Limited data are available regarding real-world prescribing in patients with an indication for oral anticoagulation (OAT) who undergo percutaneous coronary intervention (PCI). Most current guidelines recommend a period of triple therapy with OAT and dual antiplatelet (DAPT) agents over dual therapy with an OAT and DAPT but the clinical benefit is still unclear giving rise to limited evidence-based recommendations. AIM To analyze the appropriateness of OAT and anti-platelet strategies post PCI in a real-world cohort of patients in 2 academic teaching hospitals. METHODS AND RESULTS In total, 103 patients were retrospectively analyzed. As the initial 3 month stragey, 97 patients (94.2%) received triple therapy, 4 received Dual Therapy (3.9%) and 2 received DAPT (1.9%). Patients with predominant bleeding risk were significantly less likely to receive triple therapy (75% vs. 95.7% vs. 95.8%, P < 0.05). Apixaban was the most common OAT (65.7%) which in most cases was prescribed at an inappropriately reduced dose of 2.5 mg BD (80.4%). The MACE, bleeding and all-cause mortality rates did not differ significantly between groups. DISCUSSION Our study demonstrates the widespread use of triple therapy for the first 3 months of treatment in 2 Irish academic hospitals. DOACs were prescribed in most cases at reduced doses not currently known to prevent stroke. This study highlights the need for more explicit management algorithms to improve evidence-based management in this area.
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Affiliation(s)
- Robert N Kerley
- Department of Cardiology, 57983Cork University Hospital, Cork, Ireland
| | | | - John Joseph Coughlan
- Department of Cardiology, 57976Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Ciaran Kelly
- Department of Cardiology, 57976Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Max Waters
- Department of Cardiology, 57976Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Anne Reynolds
- Department of Cardiology, 57976Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - David Mulcahy
- Department of Cardiology, 57976Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - David P Moore
- Department of Cardiology, 57976Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Bryan Loo
- Department of Cardiology, 57976Tallaght University Hospital, Tallaght, Dublin, Ireland
| | - Ronan Curtin
- Department of Cardiology, 57983Cork University Hospital, Cork, Ireland
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Brunetti ND, Tricarico L, De Gennaro L, Correale M, Santoro F, Ieva R, Iacoviello M, Di Biase M. Meta-analysis study on direct oral anticoagulants vs warfarin therapy in atrial fibrillation and PCI: Dual or triple approach? IJC HEART & VASCULATURE 2020; 29:100569. [PMID: 32637570 PMCID: PMC7330069 DOI: 10.1016/j.ijcha.2020.100569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 12/31/2022]
Abstract
Background Dual antiplatelet therapy and anticoagulants may be required in the case of coexistence of coronary artery disease and atrial fibrillation (AF) undergoing (PCI), with associated increased bleeding rates. The introduction of direct oral anticoagulants (DOACs), however, significantly reduced the incidence of bleeding complications in this clinical setting of patients. We therefore sought to assess whether the recent publication of the AUGUSTUS and ENTRUST-AF PCI studies significantly impacted current evidence on the use of DOACs in AF patients treated with PCI. Methods We performed a meta-analysis of randomized controlled studies enrolling patients with nonvalvular AF undergoing PCI. We assessed pooled estimates of risk ratios (RRs) and 95%CIs for any bleeding (AB), cardiovascular events (CVE), and death at follow-up: 12,542 patients have been included in the analysis. We particularly analyzed data comparing dual anti-thrombotic therapy (DOAC plus single anti-platelet therapy) with triple (DOAC plus dual anti-platelet therapy). Results When compared with patients receiving standard triple therapy with warfarin, patients receiving DOACs had a significantly lower risk of AB (RR 0.65; 95% CI, 0.61–0.70, p < 0.00001) and of MB (RR 0.63; 95% CI, 0.53–0.73, p < 0.00001). The risk of cardiovascular events and mortality were comparable between DOAC and VKA groups (RR 1.05, 95% CI 0.93–1.18, RR 1.14, 95% CI 0.94–1.37, respectively, p n.s.). Similar results were observed comparing triple therapy vs dual therapy. Conclusions DOACs are safer than and as effective as warfarin when used in patients with AF undergoing PCI; dual therapy with DOACs is comparable to triple therapy in terms of safety and efficacy.
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Affiliation(s)
| | - Lucia Tricarico
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | | | | | - Francesco Santoro
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | | | - Massimo Iacoviello
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
| | - Matteo Di Biase
- Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy
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Galli M, Andreotti F, D'Amario D, Vergallo R, Montone RA, Niccoli G, Crea F. Randomised trials and meta-analyses of double vs triple antithrombotic therapy for atrial fibrillation-ACS/PCI: A critical appraisal. IJC HEART & VASCULATURE 2020; 28:100524. [PMID: 32435688 PMCID: PMC7229495 DOI: 10.1016/j.ijcha.2020.100524] [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: 02/18/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 12/21/2022]
Abstract
The optimal antithrombotic regimen to be used in patients with AF and PCI or ACS is still debated. Each of the six randomised controlled trials comparing double to triple therapy has limitations. None was powered to assess differences between treatment arms in ischaemic event rates. The contrasting results regarding ischaemic events within published meta-analyses can be explained by heterogeneity, incompleteness and varying definitions of stent thrombosis. The overall reduced bleeding rates, but increased early definite and probable stent thrombosis rates with double versus triple antithrombotic therapy encourage consideration of triple therapy during the first weeks from PCI followed by double therapy.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico D'Amario
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Rocco A Montone
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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Chua SK, Chen LC, Shyu KG, Cheng JJ, Hung HF, Chiu CZ, Lin CM. Antithrombotic Strategies in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention: A Systemic Review and Network Meta-Analysis of Randomized Controlled Trials. J Clin Med 2020; 9:jcm9041062. [PMID: 32276535 PMCID: PMC7231136 DOI: 10.3390/jcm9041062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 12/16/2022] Open
Abstract
Up to 10% of patients with atrial fibrillation (AF) undergo percutaneous coronary intervention (PCI). A systematic review and network meta-analysis were conducted by searching PubMed, Embase, and the Cochrane database of systematic reviews for randomized control trials that studied the safety and efficacy of different antithrombotic strategies in these patients. Six studies, including 12,158 patients were included. Compared to that in the triple antithrombotic therapy group (vitamin K antagonist (VKA) plus P2Y12 inhibitor and aspirin), thrombolysis in myocardial infarction (TIMI) major bleeding was significantly reduced in the dual antithrombotic therapy (non-vitamin K oral anticoagulants (NOACs) plus P2Y12 inhibitor) group by 47% (Odds ratio (OR), 0.53; 95% credible interval [CrI], 0.35–0.78; I2 = 0%). Besides, NOAC plus a P2Y12 inhibitor was associated with less intracranial hemorrhage compared to VKA plus single antiplatelet therapy (OR: 0.20, 95% CrI: 0.05–0.77). There was no significant difference in the trial-defined major adverse cardiac events or the individual outcomes of all-cause mortality, cardiovascular death, myocardial infarction, stroke or stent thrombosis among all antithrombotic strategies. In conclusion, antithrombotic strategy of NOACs plus P2Y12 inhibitor is safer than, and as effective as, the strategies including aspirin when used in AF patients undergoing PCI.
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Affiliation(s)
- Su-Kiat Chua
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Lung-Ching Chen
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Kou-Gi Shyu
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Jun-Jack Cheng
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Huei-Fong Hung
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
| | - Chiung-Zuan Chiu
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Correspondence: (C.-Z.C.); (C.-M.L.); Tel.: +886–2–2833–2211 (C.-Z.C. & C.-M.L.)
| | - Chiu-Mei Lin
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Department of Emergency Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan
- Correspondence: (C.-Z.C.); (C.-M.L.); Tel.: +886–2–2833–2211 (C.-Z.C. & C.-M.L.)
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Agasthi P, Lee JZ, Pujari SH, Tseng AS, Shipman J, Almader‐Douglas D, Ashraf H, Mookadam F, Fortuin FD, Beohar N, Arsanjani R, Mulpuru S. Safety and efficacy of direct oral anticoagulants compared to Vitamin K antagonists postpercutaneous coronary interventions in patients with atrial fibrillation: A systematic review and meta-analysis. J Arrhythm 2020; 36:271-279. [PMID: 32256873 PMCID: PMC7132188 DOI: 10.1002/joa3.12292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 11/28/2019] [Accepted: 12/09/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) and coronary artery disease (CAD) are commonly associated. Cotreatment with multiple antithrombotic agents can increase the risk of bleeding. We sought to evaluate patient-centered outcomes in patients with AF on double therapy with direct oral anticoagulants (DOACs) compared to patients with standard triple therapy, [a vitamin K antagonist (VKA) plus dual antiplatelet therapy]. METHODS We performed a literature search of randomized controlled trials (RCTs) reporting outcomes of patients receiving double therapy with DOACs compared to triple therapy with VKAs in patients with AF undergoing percutaneous coronary intervention (PCI). Patient-centered outcomes were the International Society of Thrombosis and Hemostasis (ISTH) major or clinically relevant nonmajor bleeding (CRNB), all-cause mortality, major adverse cardiovascular events (MACE), stent thrombosis, myocardial infarction, and stroke. RESULTS Four RCTs (9602 patients) met our inclusion criteria. Compared to VKAs, DOACs were associated with significantly lower ISTH major bleeding/ CRNB (RR: 0.75, 95% CI: 0.67-0.82, P < .00001, I 2 = 11%). There were no statistically significant differences in the efficacy outcomes, including myocardial infarction (RR: 0.99, 95% CI :0.79-1.25, P = .96), stent thrombosis (RR: 0.97, 95% CI: 0.6-1.55, P = .89), ischemic stroke (RR: 0.76, 95% CI: 0.5-1.15, P = .19), all-cause mortality (RR: 1.06, 95% CI: 0.85-1.31, P = .61), and MACE (RR: 1.06, 95% CI: 0.91-1.22, P = .97). CONCLUSION Compared with triple therapy with VKAS, double therapy with DOACs is associated with a reduced risk of bleeding and is as effective in patients with AF undergoing PCI.
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Affiliation(s)
| | - Justin Z. Lee
- Department of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
| | | | - Andrew S. Tseng
- Department of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
| | - Justin Shipman
- Department of Cardiovascular DiseasesMayo ClinicPhoenixAZUSA
| | | | - Hasan Ashraf
- Department of Cardiovascular DiseasesMayo ClinicPhoenixAZUSA
| | - Farouk Mookadam
- Department of Cardiovascular DiseasesMayo ClinicPhoenixAZUSA
| | | | - Nirat Beohar
- Department of Cardiovascular DiseasesMount Sinai Medical CenterMiamiFLUSA
| | - Reza Arsanjani
- Department of Cardiovascular DiseasesMayo ClinicPhoenixAZUSA
| | - Siva Mulpuru
- Department of Cardiovascular DiseasesMayo ClinicRochesterMNUSA
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Ravi V, Pulipati P, Vij A, Kodumuri V. Meta-Analysis Comparing Double Versus Triple Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease. Am J Cardiol 2020; 125:19-28. [PMID: 31837732 DOI: 10.1016/j.amjcard.2019.09.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/22/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
Atrial fibrillation (AF) and concomitant coronary artery disease (CAD) create a therapeutic dilemma as the risk of bleeding with triple antithrombotic therapy (TATT) must be balanced against the risk of ischemic events with double antithrombotic therapy (DATT). The aim of this meta-analysis is to compare the efficacy and safety of DATT versus TATT in AF and CAD. MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched for relevant articles published from inception to May 1, 2019. Studies comparing the safety and efficacy of DATT versus TATT in patients with AF and CAD were included. Among 9 studies, where 6,104 patients received DATT and 7,333 patients received TATT, there was no statistically significant difference in the outcomes of mortality, nonfatal myocardial infarction, stent thrombosis, and stroke. There was a lower rate of major bleeding in DATT (risk ratio [RR] 0.64 [95% confidence interval [CI] 0.54 to 0.75]; p <0.001). There was no significant difference in stent thrombosis (RR 1.52 [95% CI 0.97 to 2.38]; p = 0.07). However, subgroup analysis of trials with direct oral anticoagulant use demonstrated a borderline higher rate of stent thrombosis in DATT (RR 1.66 [95% CI 1.01 to 2.73]; p = 0.05). In conclusion, DATT showed no difference in the outcomes of mortality, stroke, nonfatal myocardial infarction, and stent thrombosis compared with TATT. DATT demonstrated a lower rate of major bleeding. DATT demonstrated a borderline higher rate of stent thrombosis in the subgroup analysis of trials with direct oral anticoagulant which needs to be evaluated in further studies.
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Al Said S, Alabed S, Kaier K, Tan AR, Bode C, Meerpohl JJ, Duerschmied D. Non-vitamin K antagonist oral anticoagulants (NOACs) post-percutaneous coronary intervention: a network meta-analysis. Cochrane Database Syst Rev 2019; 12:CD013252. [PMID: 31858590 PMCID: PMC6923523 DOI: 10.1002/14651858.cd013252.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Clinicians must balance the risks of bleeding and thrombosis after percutaneous coronary intervention (PCI) in people with an indication for anticoagulation. The potential of non-vitamin K antagonists (NOACs) to prevent bleeding complications is promising, but evidence remains limited. OBJECTIVES To review the evidence from randomised controlled trials assessing the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) compared to vitamin K antagonists post-percutaneous coronary intervention (PCI) in people with an indication for anticoagulation. SEARCH METHODS We identified studies by searching CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science and two clinical trials registers in February 2019. We checked bibliographies of identified studies and applied no language restrictions. SELECTION CRITERIA We searched for randomised controlled trials (RCT) that compared NOACs and vitamin K antagonists for people with an indication for anticoagulation who underwent PCI. DATA COLLECTION AND ANALYSIS Two review authors independently checked the results of searches to identify relevant studies, assessed each included study, and extracted study data. We conducted random-effects, pairwise analyses using Review Manager 5 and network meta-analyses (NMA) using the R package 'netmeta'. We ranked competing treatments by P scores, which are derived from the P values of all pairwise comparisons, and allow ranking of treatments on a continuous 0 to 1 scale. MAIN RESULTS We identified nine RCTs that met the inclusion criteria, but four were ongoing trials, and were not included in this analysis. We included five RCTs, with 8373 participants, in the NMA (two RCTs compared apixaban to a vitamin K antagonist, two RCTs compared rivaroxaban to a vitamin K antagonist, and one RCT compared dabigatran to a vitamin K antagonist). Very low- to moderate-certainty evidence suggests little or no difference between NOACs and vitamin K antagonists in death from cardiovascular causes (not reported in the dabigatran trial), myocardial infarction, stroke, death from any cause, and stent thrombosis. Apixaban (RR 0.85, 95% CI 0.77 to 0.95), high dose rivaroxaban (RR 0.86, 95% CI 0.74 to 1.00), and low dose rivaroxaban (RR 0.80, 95% CI 0.68 to 0.92) probably reduce the risk of recurrent hospitalisation compared with vitamin K antagonists. No studies looked at health-related quality of life. Very low- to moderate-certainty evidence suggests that NOACs may be safer than vitamin K antagonists in terms of bleeding. Both high dose dabigatran (RR 0.53, 95% CI 0.29 to 0.97), and low dose dabigatran (RR 0.38, 95% CI 0.21 to 0.70) may reduce major bleeding more than vitamin K antagonists. High dose dabigatran (RR 0.83, 95% CI 0.72 to 0.96), low dose dabigatran (RR 0.66, 95% CI 0.58 to 0.75), apixaban (RR 0,67 , 95% Cl 0.51 to 0.88), high dose rivaroxaban (RR 0.66, 95% CI 0.52 to 0.83), and low dose rivaroxaban (RR 0.71, 95% CI 0.57 to 0.88) probably reduce non-major bleeding more than vitamin K antagonists. The results from the NMA were inconclusive between the different NOACs for all primary and secondary outcomes. AUTHORS' CONCLUSIONS Very low- to moderate-certainty evidence suggests no meaningful difference in efficacy outcomes between non-vitamin K antagonist oral anticoagulants (NOAC) and vitamin K antagonists following percutaneous coronary interventions (PCI) in people with non-valvular atrial fibrillation. NOACs probably reduce the risk of recurrent hospitalisation for adverse events compared with vitamin K antagonists. Low- to moderate-certainty evidence suggests that dabigatran may reduce the rates of major and non-major bleeding, and apixaban and rivaroxaban probably reduce the rates of non-major bleeding compared with vitamin K antagonists. Our network meta-analysis did not show superiority of one NOAC over another for any of the outcomes. Head to head trials, directly comparing NOACs against each other, are required to provide more certain evidence.
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Affiliation(s)
- Samer Al Said
- University of Freiburg, Department of Cardiology and Angiology I, Heart Center, Freiburg, Germany
| | - Samer Alabed
- University of Sheffield, Academic Unit of Radiology, Sheffield, UK
| | - Klaus Kaier
- Faculty of Medicine and Medical Center, University of Freiburg, Institute for Medical Biometry and Statistics, Freiburg, Germany
| | - Audrey R Tan
- University College London, Institute of Health Informatics Research, 222 Euston Road, London, UK, NW1 2DA
| | - Christoph Bode
- University of Freiburg, Department of Cardiology and Angiology I, Heart Center, Freiburg, Germany
| | - Joerg J Meerpohl
- Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Institute for Evidence in Medicine, Breisacher Str. 153, Freiburg, Germany, D-79110
| | - Daniel Duerschmied
- University of Freiburg, Department of Cardiology and Angiology I, Heart Center, Freiburg, Germany
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D'Ascenzo F, Gaido L, Bernardi A, Saglietto A, Franzé A, Ielasi A, Trabattoni D, Di Biasi M, Infantino V, Rognoni A, Helft G, Gangor A, Latini RA, De Luca L, Mitomo S, Ugo F, Smolka G, Huczek Z, Cortese B, Capodanno D, Chieffo A, Piazza F, di Mario C, Poli A, D'Urbano M, Romeo F, Giammaria M, Varbella F, Sheiban I, Escaned J, De Ferrari GM. Safety and efficacy of polymer-free biolimus-eluting stents versus ultrathin stents in unprotected left main or coronary bifurcation: A propensity score analysis from the RAIN and CHANCE registries. Catheter Cardiovasc Interv 2019; 95:522-529. [PMID: 31385427 DOI: 10.1002/ccd.28413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 06/05/2019] [Accepted: 07/10/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Evaluate safety and efficacy of polymer-free biolimus-eluting stents (PF-BESs) versus ultrathin stents in unprotected left main (ULM) or bifurcation. BACKGROUND PF-BESs due to reduced length of dual antiplatelet therapy (DAPT) are increasingly used. However, there are limited data about safety and efficacy for ULM or bifurcation. METHODS We selected all-patients treated for ULM or bifurcation from two multicenter real life registries (RAIN [NCT03544294] evaluating ultrathin stents, CHANCE [NCT03622203] appraising PF-BES). After propensity score with matching, the primary endpoint was major adverse cardiac events (MACE; a composite of all-cause death, myocardial infarction, target lesion revascularization [TLR], and stent thrombosis [ST]), while its components along with target vessel revascularization (TVR) secondary endpoints. RESULTS Three thousand and three patients treated with ultrathin stents and 446 with PF-BESs, resulting respectively in 562 and 281 after propensity score with matching (33 and 22%, respectively, with ULM disease). After 12 (8-20) months, rates of MACE were similar (9 vs. 8%, p = 0.56) without difference in TLR and ST (3.0 vs. 1.7%, p = .19 and 1.8 vs. 1.1%, p = .42). These results were consistent for ULM group (3 vs. 1.7% and 1.8 vs. 1.1%, p = .49 and .76), for non-ULM group (2.1 vs. 3.4%, p = .56 and 1.2 vs. 1.7%, p = .78) and for two-stent strategy (8.7 vs. 4.5% and 4.3 vs. 3.2%, p = .75 and .91). Among patients treated with 1 month of DAPT in both groups, those with ultrathin stents experienced higher rates of MACE related to all-cause death (22 vs. 12%, p = .04) with higher although not significant rates of ST (3 vs. 0%, p = .45). CONCLUSIONS PF-BES implanted on ULM or BiF offered freedom from TLR and ST comparable to ultrathin stents. PF-BESs patients assuming DAPT for 1 month experienced a lower despite not significant incidence of ST.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, A.O.U. Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Luca Gaido
- Division of Cardiology, Ospedale Maria Vittoria, Turin, Italy
| | - Alessandro Bernardi
- Division of Cardiology, A.O.U. Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Andrea Saglietto
- Division of Cardiology, A.O.U. Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Alfonso Franzé
- Division of Cardiology, A.O.U. Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center, Milan, Italy
| | - Daniela Trabattoni
- Department of Cardiovascular Sciences, IRCCS Centro Cardiologico Monzino, Milan, Italy.,Division of Cardiology, University of Milan, Milan, Italy
| | - Maurizio Di Biasi
- Cardiology Unit, ASST Fatebenefratelli/Sacco, Sacco Hospital, Milan, Italy
| | | | - Andrea Rognoni
- Coronary Care Unit and Catheterization Laboratory, A.O.U. Maggiore della Carità, Novara, Italy
| | - Gerard Helft
- Division of Cardiology, Pierre and Marie Curie University, Paris, France
| | - Andrea Gangor
- Division of Cardiology, Ospedale Maria Vittoria, Turin, Italy
| | - Roberto A Latini
- Interventional Cardiology, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Leonardo De Luca
- Division of Cardiology, S. Giovanni Evangelista Hospital, Tivoli, Rome, Italy
| | - Satoru Mitomo
- Department of Cardiovascular Medicine, Nippon Medical School, Bunkyo-ku, Tokyo, Japan
| | - Fabrizio Ugo
- Dipartimento di Cardiologia, Ospedale San Giovanni Bosco, Italy
| | - Grzegorz Smolka
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Zenon Huczek
- Division of Cardiology, University Clinical Hospital, Warsaw, Poland
| | | | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Alaide Chieffo
- Division of Cardiology, San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Piazza
- Cardiology Unit-Catheterization Laboratory, SS. Annunziata Hospital, University Hospital of Sassari, Sassari, Italy
| | - Carlo di Mario
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Arnaldo Poli
- ASST Milanese Ovest, Legnano Civil Hospital, Legnano, Milan, Italy
| | - Maurizio D'Urbano
- Cardiology Unit, ASST Milanese Ovest, Magenta Hospital, Magenta, Milan, Italy
| | - Francesco Romeo
- Department of Medicine, Università degli Studi di Roma 'Tor Vergata', Rome, Italy
| | | | - Ferdinando Varbella
- Department of Cardiology, Infermi Hospital, Rivoli, Italy.,Department of Cardiology, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Imad Sheiban
- Division of Cardiology, Interventional Cardiology Pederzoli Hospital Peschiera del Garda, Verona, Italy
| | - Javier Escaned
- Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Gaetano M De Ferrari
- Division of Cardiology, A.O.U. Città della Salute e della Scienza, University of Turin, Turin, Italy
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