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Park J, Jung JH, Choi EK, Lee SW, Kwon S, Lee SR, Kang J, Han KD, Park KW, Oh S, Lip GYH. Comparison of early clinical outcomes between dual antiplatelet therapy and triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. PLoS One 2022; 17:e0264538. [PMID: 35213632 PMCID: PMC8880831 DOI: 10.1371/journal.pone.0264538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background and objective Most Asian patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) receive only dual antiplatelet therapy (DAPT) without oral anticoagulants (vitamin K antagonists [VKA] or non-VKA oral anticoagulants [NOAC]). However, it has not been fully investigated whether the DAPT results in better clinical outcomes in the early period after PCI than the standard triple therapy with VKA or NOAC. Methods We analyzed the claims records of 11,039 Korean AF population who had PCI between 2013 and 2018. Patients were categorized according to the post-PCI antithrombotic therapy as VKA-based triple therapy (VKA-TT), NOAC-based triple therapy (NOAC-TT), and DAPT groups. After baseline adjustment using inverse probability weighting, we compared the risks of ischemic endpoints (ischemic stroke, myocardial infarction, and all-cause mortality) and major bleeding at 3 months post-PCI. Results Ischemic stroke, MI, and all-cause mortality occurred in 105, 423, and 379 patients, respectively, and 138 patients experienced major bleeding. The DAPT group was associated with a lower risk of ischemic stroke and major bleeding (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37–0.84) compared to the VKA-TT group, despite no significant differences in the risks of MI and all-cause mortality. In contrast, the DAPT group demonstrated no significant difference in the risks for ischemic endpoints compared to the NOAC-TT group. Additionally, the DAPT group had a numerically lower risk of major bleeding than the NOAC-TT group but this was not statistically significant (HR 0.69, 95% CI 0.45–1.07). Conclusions An outcome benefit of DAPT was observed in the early period after PCI compared to the VKA-TT, but not against NOAC-TT users among the Asian AF population. Given the potential long-term benefits of NOACs, greater efforts should be made to increase compliance in clinical practice with proper combination therapy with NOAC after PCI.
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Affiliation(s)
- Jiesuck Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Hyung Jung
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- * E-mail:
| | - Seung-Woo Lee
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Gregory Y. H. Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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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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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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Triple therapy after PCI - Warfarin treatment quality and bleeding risk. PLoS One 2018; 13:e0209187. [PMID: 30562365 PMCID: PMC6298652 DOI: 10.1371/journal.pone.0209187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 12/01/2018] [Indexed: 11/28/2022] Open
Abstract
Background A combination of warfarin, aspirin and clopidogrel is indicated after percutaneous coronary intervention (PCI) in some patients, despite the higher risk of bleeding inferred by this triple therapy. Objectives Whether the treatment quality of warfarin measured by iTTR (individual time within therapeutic INR range) is associated with bleeding complications during triple therapy after PCI. Methods A retrospective register study consisting of 601 triple treated PCI patients from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). The cohort was cross-matched with the Swedish Patient Registry for background characteristics and bleeding complications up to 6 months after PCI using ICD10 codes, the Prescribed Drug Registry for ongoing medications, and the national oral anticoagulation registry Auricula for warfarin treatment quality. The patients were grouped into four iTTR groups: <50%, 50–69.9%, 70–84.9% and >85% as well as iTTR above or below 70%. Results Of 601 patients, 39 (6.5%) had a bleeding complication (type 2 according to BARC). Bleeding was more common for iTTR<70% compared to iTTR>70%, 28 (9.3%) vs. 11 (3.7%) (p = 0.005). The bleeding frequency increased gradually from the best group, iTTR>85% with four bleeders (3.3%) up to 17 bleeders (13.3%) in the worst group with iTTR<50% (p = 0.003), with a corresponding bleeding rate per 100 treatment years of 8.0 and 44.9, respectively. In multivariate analysis low BMI, HR 1.11 (95% CI 1.01–1.22), a medical history of anemia HR 3.17 (1.16–8.69) and iTTR < 70% HR 2.86 (1.25–6.53) increased the risk of bleeding. Conclusion Triple therapy after PCI confers a high risk of bleeding events. Warfarin treatment quality measured by iTTR as well as a medical history of anemia are strong independent predictors of bleeding in these patients. Physicians should pay more attention to iTTR after PCI.
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