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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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2
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Toma MM, Bungau SG, Tit DM, Moisi MI, Bustea C, Vesa CM, Behl T, Stoicescu M, Brisc CM, Purza LA, Gitea D, Diaconu CC. Use of anticoagulant drugs in patients with atrial fibrillation. Does adherence to therapy have a prognostic impact? Biomed Pharmacother 2022; 150:113002. [PMID: 35462339 DOI: 10.1016/j.biopha.2022.113002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/10/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022] Open
Abstract
Anticoagulant therapy represents a pivotal element that strongly influences the thromboembolic risk of non-valvular atrial fibrillation (NVAF) subjects. The main purpose of this review was to identify issues and suggest strategies to improve the oral anticoagulants (OACs) treatment adherence, which is the most important predictor of NVAF outcome. Advantages, efficacy, and impact of these drugs on patients' prognosis were revealed in important clinical trials on large cohorts of patients and are often prescribed nowadays. A real-life data registry, the Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) analyzed the profile and outcome of patients diagnosed with NVAF receiving oral antithrombotic treatment. The observations gathered in the registry were crucial for identifying relevant elements that clinicians must improve, such as adherence strategies and predisposing factors that correlated with stroke. Adherence to OACs in AF patients is essential from the viewpoint of clinical efficacy and safety. Major adverse events and negative outcome are correlated with a weak anticoagulation control caused by an ineffective treatment adherence strategy. Solving the issue of oral anticoagulation adherence is possible using new technologies, but future directions should be explored. Mobile phone applications centered on patients' needs, telemedicine programs that evaluate patients' evolution and detect adverse reactions or events, encouraging an adequate management of the event without interruption of OACs, represent perspectives with a major impact on treatment adherence.
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Affiliation(s)
- Mirela Marioara Toma
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania.
| | - Simona Gabriela Bungau
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Delia Mirela Tit
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Madalina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, 140401 Punjab, India.
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Cristina Mihaela Brisc
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Lavinia Anamaria Purza
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Daniela Gitea
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Camelia Cristina Diaconu
- Department 5, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania; Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania.
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Lyu SQ, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Yang YM. Predictive performance of different bleeding risk scores in patients with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention. Platelets 2022; 33:900-910. [PMID: 35103582 DOI: 10.1080/09537104.2021.2007870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This study aims to evaluate the predictive values of the HAS-BLED, ORBIT, ATRIA, REACH, PARIS, and PRECISE-DAPT scores in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) who received both anticoagulant and antiplatelet therapy. 930 patients were consecutively recruited and followed up for 1 year. The primary endpoints were BARC class ≥3 bleeding and BARC class ≥2 bleeding. BARC class ≥3 bleeding occurred in 36 patients(3.9%), while BARC class ≥2 bleeding was seen in 134 patients (14.4%). The predictive performance of the HAS-BLED score for BARC class ≥3 bleeding was unsatisfactory (c-statistic = 0.575). The discrimination of the ATRIA, ORBIT, PARIS, and PRECISE-DAPT scores was also low-to-moderate. The REACH score was useless in bleeding risk stratification for this population. Multivariable logistic regression indicated that previous bleeding events and hemoglobin were two independent predictors of BARC class ≥3 bleeding. Compared to the HAS-BLED score, the model constructed by previous bleeding events and hemoglobin displayed a significant improvement in bleeding risk prediction [c-statistics: 0.704 vs. 0.575 (p = .008), NRI = 0.662,IDI = 0.049]. In patients with AF and ACS or undergoing PCI who received anticoagulant+antiplatelet therapy, the HAS-BLED, ORBIT, ATRIA, REACH, PARIS, and PRECISE-DAPT scores displayed only low-to-moderate performance in predicting BARC class≥3 bleeding. Future studies are required to develop more reliable scoring systems for bleeding risk evaluation in this population.
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Affiliation(s)
- Si-Qi Lyu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jun Zhu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Juan Wang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shuang Wu
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Han Zhang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xing-Hui Shao
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan-Min Yang
- Emergency and Critical Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Vella D, Monteleone A, Musotto G, Bosi GM, Burriesci G. Effect of the Alterations in Contractility and Morphology Produced by Atrial Fibrillation on the Thrombosis Potential of the Left Atrial Appendage. Front Bioeng Biotechnol 2021; 9:586041. [PMID: 33718333 PMCID: PMC7952649 DOI: 10.3389/fbioe.2021.586041] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/09/2021] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) is a common arrhythmia mainly affecting the elderly population, which can lead to serious complications such as stroke, ischaemic attack and vascular dementia. These problems are caused by thrombi which mostly originate in the left atrial appendage (LAA), a small muscular sac protruding from left atrium. The abnormal heart rhythm associated with AF results in alterations in the heart muscle contractions and in some reshaping of the cardiac chambers. This study aims to verify if and how these physiological changes can establish hemodynamic conditions in the LAA promoting thrombus formation, by means of computational fluid dynamic (CFD) analyses. In particular, sinus and fibrillation contractility was replicated by applying wall velocity/motion to models based on healthy and dilated idealized shapes of the left atrium with a common LAA morphology. The models were analyzed and compared in terms of shear strain rate (SSR) and vorticity, which are hemodynamic parameters directly associated with thrombogenicity. The study clearly indicates that the alterations in contractility and morphology associated with AF pathologies play a primary role in establishing hemodynamic conditions which promote higher incidence of ischaemic events, consistently with the clinical evidence. In particular, in the analyzed models, the impairment in contractility determined a decrease in SSR of about 50%, whilst the chamber pathological dilatation contributed to a 30% reduction, indicating increased risk of clot formation. The equivalent rigid wall model was characterized by SSR values about one order of magnitude smaller than in the contractile models, and substantially different vortical behavior, suggesting that analyses based on rigid chambers, although common in the literature, are inadequate to provide realistic results on the LAA hemodynamics.
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Affiliation(s)
- Danila Vella
- Bioengineering Unit, Ri. MED Foundation, Palermo, Italy
| | | | - Giulio Musotto
- Bioengineering Unit, Ri. MED Foundation, Palermo, Italy.,Department of Mechanical Engineering, University of Palermo, Palermo, Italy
| | - Giorgia Maria Bosi
- UCL Mechanical Engineering, University College London, London, United Kingdom
| | - Gaetano Burriesci
- Bioengineering Unit, Ri. MED Foundation, Palermo, Italy.,UCL Mechanical Engineering, University College London, London, United Kingdom
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5
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Nabi H, Rørth R, Tajchman DH, Holmvang L, Torp-Pedersen C, Gislason G, Fosbøl EL, Køber L, Sørensen R. Antithrombotic treatment and major adverse cardiac events after bleeding in patients with myocardial infarction: a retrospective analysis of nationwide registry data. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 6:14-21. [PMID: 31274145 DOI: 10.1093/ehjcvp/pvz025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/10/2019] [Accepted: 07/03/2019] [Indexed: 11/14/2022]
Abstract
AIMS The aim of this study was to describe the use of antithrombotic therapy following a bleeding event among patients with myocardial infarction (MI), and the associated risk of major adverse cardiac events (MACE). METHODS AND RESULTS Using Danish nationwide registries, patients hospitalized with a bleeding event within 1 year after MI were identified. Antithrombotic treatment with aspirin, clopidogrel, and/or vitamin K antagonists (VKA) was determined at the bleeding and at Day 90 and 180 post-bleed. Based on guidelines, patients were stratified into four groups: expected, reduced, discontinued, or intensified treatment. Risk of MACE (ischaemic stroke, MI, or death) within the first year was assessed by Cox proportional hazard models. A total of 3324 patients with a bleeding after MI were included. At Day 90 post-bleed, 1052 (31.7%) received expected antithrombotic treatment, 1301 (39.2%) reduced, 164 (4.9%) intensified, and 807 (24.3%) no treatment. Major adverse cardiac events occurred in 637 (19.2%) patients. With dual antiplatelet therapy as reference, adjusted hazard ratios for MACE were: aspirin 1.81 (1.06-3.09), clopidogrel 1.08 (0.64-1.82), VKA 1.08 (0.47-2.48), VKA + aspirin 1.97 (0.95-4.07), VKA + clopidogrel 0.26 (0.03-1.91), triple 1.73 (0.50-5.95), and no treatment 1.93 (1.11-3.36). CONCLUSION The majority of MI patients reduced or discontinued their antithrombotic therapy post-bleed. Patients in monotherapy with aspirin or no treatment post-bleed had a higher risk of MACE Further studies of optimal antithrombotic treatments after a bleed are needed.
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Affiliation(s)
- Hafsah Nabi
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Rasmus Rørth
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Daniel H Tajchman
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Hobrovej 18-22, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D2, Aalborg Øst, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Gentofte Hospitalsvej 6, 3. Sal, Hellerup, Denmark.,The Danish Heart Foundation, Vognmagergade 7, 3.sal, 1120 København K, Denmark.,The National Institute of Public Health, University of Southern Denmark, Studiestræde 6, København K, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Afsnit 2142, Opgang 2, 14. Sal, Inge Lehmanns vej 7, København Ø, Denmark
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6
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Knijnik L, Rivera M, Blumer V, Cardoso R, Fernandes A, Fernandes G, Ferreira T, Romano JG, Lambrakos LK, Cohen MG. Prevention of Stroke in Atrial Fibrillation After Coronary Stenting. Stroke 2019; 50:2125-2132. [PMID: 31303150 DOI: 10.1161/strokeaha.119.026078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The optimal antithrombotic strategy to balance thromboembolic and bleeding events, especially acute stroke, for patients with atrial fibrillation following coronary stenting remains a matter of debate. We conducted a network meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in atrial fibrillation after coronary stenting. Methods- PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials and observational studies of patients with atrial fibrillation after coronary stenting. The outcomes of interest were stroke, myocardial infarction, major adverse cardiac events, mortality, and major bleeding. A network meta-analysis was performed comparing the available antithrombotic regimens in the literature. Results- Three randomized and 15 observational studies were included, with a total of 23 478 participants. Median follow-up was 2 years. Network meta-analysis demonstrated that vitamin K antagonist plus single antiplatelet therapy or direct-acting oral anticoagulant plus single antiplatelet therapy were the most effective regimens in preventing stroke. Direct-acting oral anticoagulant regimens were associated with lower major bleeding rates than vitamin K antagonist regimens. Regimens with dual antiplatelet therapy were associated with lower rates of myocardial infarction. Vitamin K antagonist plus dual antiplatelet therapy was associated with a lower mortality and low-dose direct-acting oral anticoagulants with decreased major cardiovascular adverse events. Conclusions- Direct-acting oral anticoagulant regimens were associated with less major bleeding and major cardiovascular adverse events, but vitamin K antagonists were associated with decreased mortality and stroke. These results suggest that the decision of antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention needs to be individualized.
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Affiliation(s)
- Leonardo Knijnik
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Manuel Rivera
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.R.)
| | - Vanessa Blumer
- Cardiovascular Division, Duke University Hospital, Durham, NC (V.B.)
| | - Rhanderson Cardoso
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD (R.C.)
| | - Amanda Fernandes
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Gilson Fernandes
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Tanira Ferreira
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Jose G Romano
- Department of Neurology (J.G.R.), University of Miami Miller School of Medicine, FL
| | - Litsa K Lambrakos
- Cardiovascular Division, Department of Medicine (L.K.L., M.G.C.), University of Miami Miller School of Medicine, FL
| | - Mauricio G Cohen
- Cardiovascular Division, Department of Medicine (L.K.L., M.G.C.), University of Miami Miller School of Medicine, FL
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Bunmark W, Jinatongthai P, Vathesatogkit P, Thakkinstian A, Reid CM, Wongcharoen W, Chaiyakunapruk N, Nathisuwan S. Antithrombotic Regimens in Patients With Percutaneous Coronary Intervention Whom an Anticoagulant Is Indicated: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2018; 9:1322. [PMID: 30510510 PMCID: PMC6252311 DOI: 10.3389/fphar.2018.01322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 10/29/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Patients undergoing percutaneous coronary intervention (PCI) who require anticoagulant therapy are at increased risk of bleeding. The optimal regimen for these patients is uncertain. This study aimed to compare safety and efficacy of antithrombotic regimens used in patients undergoing PCI with concomitant anticoagulant therapy. Methods: A systematic review and network meta-analysis was performed among studies comparing antithrombotic regimens for anticoagulated patients undergoing PCI. The primary outcome of interest was major bleeding. The secondary outcomes were coronary events. The reference intervention was classic triple therapy (aspirin plus clopidogrel plus VKA). Cluster rank incorporating risk (major bleeding) and benefit (all-cause death) was performed to identify the most appropriate regimen(s). Results: There were 3 RCTs (6 interventions) and 29 non-RCTs (8 interventions) that met the inclusion criteria with 22,179 patients. Network meta-analysis of RCTs indicated that dual therapy (DT), either with vitamin K antagonist (VKA) or direct anticoagulant (DOAC) plus an antiplatelet, significantly reduced the risk of major bleeding compared to triple therapy (TT) [pooled RR of 0.51 (0.30-0.87) and 0.68 (0.49-0.94), respectively]. In addition, VKA-DT significantly reduced the risk of all-cause death compared to TT [pooled RR of 0.40 (0.17-0.93)]. Results from network meta-analysis of non-RCT paralleled that of RCTs. No significant differences of coronary events were found. Conclusions: In conclusion, for anticoagulated patients undergoing PCI, dual therapy, either with warfarin or DOAC plus an antiplatelet, should be considered due to its optimal balance on efficacy and safety.
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Affiliation(s)
- Wipharak Bunmark
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Peerawat Jinatongthai
- Pharmacy Practice Division, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor, Malaysia
| | - Prin Vathesatogkit
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Christopher M Reid
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,School of Public Health, Curtin University, Perth, WA, Australia
| | - Wanwarang Wongcharoen
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research (CPOR), Naresuan University, Phitsanulok, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor, Malaysia.,School of Pharmacy, University of Wisconsin, Madison, WI, United States.,Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
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8
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Yoshida R, Morishima I, Takagi K, Morita Y, Tsuboi H, Murohara T. Comparison Between Long-Term Clinical Outcomes of Vitamin K Antagonist and Direct Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Circ J 2018; 82:2016-2024. [DOI: 10.1253/circj.cj-17-1171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ruka Yoshida
- Department of Cardiology, Ogaki Municipal Hospital
| | | | | | | | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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9
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Tang YD, Wang W, Yang M, Zhang K, Chen J, Qiao S, Yan H, Wu Y, Huang X, Xu B, Gao R, Yang Y, Yuan X, Ji H, Zhou Z, Liu Z, Chen J, Yuan J, Liu H, Qian J, Hu F, Shao C, Zhao H, Hua Y, Lu J. Randomized Comparisons of Double-Dose Clopidogrel or Adjunctive Cilostazol Versus Standard Dual Antiplatelet in Patients With High Posttreatment Platelet Reactivity. Circulation 2018; 137:2231-2245. [DOI: 10.1161/circulationaha.117.030190] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 01/17/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Yi-Da Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Wenyao Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Min Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Kuo Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Jing Chen
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Shubin Qiao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Hongbing Yan
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Yongjian Wu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Xiaohong Huang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Bo Xu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Runlin Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
| | - Yuejin Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Department of Cardiology (X.Y., J.C., J.Y., H.L., J.Q., F.H., C.S., H.Z., Y.H., J.L.), Department of Anesthesiology (H.J.), State Key Laboratory of Cardiovascular Disease; and Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service
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Li JX, Li Y, Yan SJ, Han BH, Song ZY, Song W, Liu SH, Guo JW, Yin S, Chen YP, Xia DJ, Li X, Li XQ, Jin EZ. Optimal antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: A systemic review and meta-analysis. Biomed Rep 2018; 8:138-147. [PMID: 29435272 PMCID: PMC5778825 DOI: 10.3892/br.2017.1036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/17/2017] [Indexed: 01/11/2023] Open
Abstract
A challenge for antithrombotic treatment is patients who present with atrial fibrillation (AF) and acute coronary syndrome, particularly in patients who have undergone coronary percutaneous intervention with stenting (PCIS). In the present study, a total of nine observational trials published prior to July 2017 that investigated the effects of dual antiplatelet therapy (DAPT; aspirin + clopidogrel) and triple oral antithrombotic therapy (TOAT; DAPT + warfarin) among patients with AF concurrent to PCIS were collected from the Medline, Cochrane and Embase databases and conference proceedings of cardiology, gastroenterology and neurology meetings. A meta-analysis was performed using fixed- or random-effect models according to heterogeneity. The subgroups were also analyzed on the occurrence of major adverse cardiac events (MACE), stroke and bleeding events in the two treatment groups. Analysis of baseline characteristics indicated that there was no significant difference in the history of coexistent disease or conventional therapies between the DAPT and TOAT groups. The primary end point incidence was 2,588 patients in the DAPT group (n=13,773) and 871 patients in the TOAT group (n=5,262) following pooling of all nine trials. There was no statistically significant difference in the incidence of primary end points between the DAPT and TOAT groups. Odds ratio (OR)=0.96, 95% confidence interval (CI)=0.73-1.27, P=0.79, with heterogeneity between trials (I2=82%, P<0.00001). Subsequently, on subgroup analysis, the results indicated no increased risk of major bleeding or ischemic stroke in the DAPT or TOAT group. However, compared with the TOAT group, there was an apparent increased risk of MACE plus ischemic stroke in the DAPT group (OR=1.62, 95% CI=1.43-1.83, P<0.00001) with heterogeneity between trials (I2=70%, P=0.01). In conclusion, the present meta-analysis suggests that TOAT (aspirin + clopidogrel + warfarin) therapy for patients with AF concurrent to PCIS significantly reduced the risk of MACE and stroke compared with DAPT (aspirin + clopidogrel) therapy. Further randomized controlled clinical trials are required to confirm the efficacy of the optimal antithrombotic therapy in patients with AF following PCIS.
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Affiliation(s)
- Jing-Xiu Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Yang Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Shu-Jun Yan
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Bai-He Han
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Zhao-Yan Song
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Wei Song
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Shi-Hao Liu
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Ji-Wei Guo
- Department of Cardiology, Harbin First Hospital, Harbin, Heilongjiang 150001, P.R. China
| | - Shuo Yin
- Department of Pharmacy, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Ye-Ping Chen
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - De-Jun Xia
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Xin Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - Xue-Qi Li
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
| | - En-Ze Jin
- Department of Cardiology, The Fourth Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150001, P.R. China
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Dual (Anticoagulant Plus Single Antiplatelet) vs Triple (Anticoagulant Plus Dual Antiplatelet) Antithrombotic Therapy – “Real World” Experience. Prog Cardiovasc Dis 2018. [DOI: 10.1016/j.pcad.2018.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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12
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Huber K, Lip G, Marín F. Antithrombotic therapy in atrial fibrillation and stent implantation: treatment or threats by the use of triple or dual antithrombotic therapy. Thromb Haemost 2017; 110:623-5. [DOI: 10.1160/th13-08-0677] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/20/2013] [Indexed: 11/05/2022]
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13
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Bishara R, Telman G, Bahouth F, Lessick J, Aronson D. Transient atrial fibrillation and risk of stroke after acute myocardial infarction. Thromb Haemost 2017; 106:877-84. [DOI: 10.1160/th11-05-0343] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 07/15/2011] [Indexed: 11/05/2022]
Abstract
SummaryAtrial fibrillation (AF) is a frequent complication of acute myocardial infarction (AMI). In the AMI setting, AF is frequently brief and attributed to acute haemodynamic changes, inflammation or ischaemia. However, it remains uncertain whether transient AF episodes are associated with a subsequent increased risk of ischaemic stroke. We studied the impact of transient new-onset AF on the one-year risk of ischaemic stroke or transient ischaemic attack (TIA) in a retrospective cohort of 2,402 patients with AMI. Patients with previous AF or AF at hospital discharge were excluded. Transient AF occurred in 174 patients (7.2%) during the initial hospitalisation. During one year follow-up after hospital discharge, stroke or TIA occurred in 16 (9.2%) and 58 (2.6%) patients with and without transient AF, respectively (p< 0.0001). Compared with patients without transient AF, the adjusted hazard ratio for stroke or TIA in patients with transient AF was 3.03 (95% CI 1.73–5.32; p< 0.0001). Stroke or TIA occurred in 2.6% of patients without AF, 6.3% of patients with transient AF treated with oral anticoagulants, and 9.9% of patients with transient AF treated with antiplatelet agents. The incidence of recurrent AF after hospital discharge was markedly higher in patients with transient AF during the index hospitalisation (22.8% vs. 2.0%, p< 0.0001). In conclusion, transient AF complicating AMI is associated with an increased future risk of ischaemic stroke and TIA, particularly in patients treated with antiplatelet agents alone. High AF recurrence rates in these patients also suggest that oral anticoagulants should be strongly considered.
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Cambronero F, Caro-Martínez C, Hurtado-Martínez JA, Marín F, Pastor-Pérez FJ, Mateo-Martínez A, Sánchez-Martínez M, Pinar-Bermúdez E, Valdés M, Manzano-Fernández S. Mild kidney disease as a risk factor for major bleeding in patients with atrial fibrillation undergoing percutaneous coronary stenting. Thromb Haemost 2017; 107:51-8. [DOI: 10.1160/th11-08-0524] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/30/2011] [Indexed: 01/03/2023]
Abstract
SummaryBleeding risk is increased in patients with atrial fibrillation (AF) and moderate to severe kidney disease (KD); however, the implication of mild KD on bleeding remains unclear. The aim of this study was to determine whether the presence of mild KD increases risk for major bleeding (MB) in patients with AF undergoing percutaneous coronary intervention with stent implantation (PCI-S). Two hundred eighty-five patients were included. Patients were classified into three kidney function groups: moderate to severe KD (n=91; <60 ml/min/1.73 m2), mild KD (n=139; 60–89 ml/min/1.73 m2) and non-KD (n=55; ≥90 ml/min/1.73 m2). Estimated glomerular filtration rate was calculated using the simplified Modification of Diet in Renal Disease equation. Patients were followed for one year, and the occurrence of MB was obtained in all. A total of 28 patients (9.8%) presented MB. MB complications examined as a function of KD groups revealed that there was a graded increase in MB with worsening renal function (non KD=1.8%, mild KD=7.9%, moderate to severe KD=17.6%; p <0.001). Multivariable Cox regression analysis showed that mild KD was associated with nearly a 2.5-fold (2.43 95% confidence interval 1.11–5.34, p=0.039) increase in the risk of MB as compared with non-KD patients. Other independent predictors of MB were moderate-severe KD, anaemia and triple antithrombotic therapy after PCI-S (C-index=0.76). In this population, mild KD confers a significantly increase in the risk for MB complications. Future studies should assess the potential role of incorporating mild KD into the bleeding risk scales to improve the stratification of these patients.
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Batra G, Friberg L, Erlinge D, James S, Jernberg T, Svennblad B, Wallentin L, Oldgren J. Antithrombotic therapy after myocardial infarction in patients with atrial fibrillation undergoing percutaneous coronary intervention. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2017; 4:36-45. [DOI: 10.1093/ehjcvp/pvx033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/03/2017] [Indexed: 12/17/2022]
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Khan SU, Saleem MA, Abdullah A, Ghimire S, Lekkala M, Rahman H, Lone AN, Kaluski E. Safety and efficacy of anti-thrombotic regimens in patients with percutaneous coronary intervention requiring oral anticoagulation: A traditional and network meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:535-543. [PMID: 28457807 DOI: 10.1016/j.carrev.2017.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 04/08/2017] [Accepted: 04/19/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Previous reports have been inconsistent in generating a consensus for optimal treatment strategy for patients with percutaneous coronary intervention (PCI) who also require oral anticoagulation (OAC). We conducted a traditional and network meta-analysis to evaluate the safety and efficacy of anti-thrombotic regimens in this subset of patients. METHODS 30 articles were recovered through preferred reporting items for systematic reviews and meta-analyses (PRISMA) using MEDLINE, EMBASE and Cochrane Central Register of Controlled Clinical Trials (CENTRAL) from inception to December 2016. RESULTS Dual antiplatelet therapy (DAPT) was found to be the safest treatment modality when compared to triple therapy (TT) or combination of OAC and single antiplatelet agent (OAC+SAP) [Major bleeding: (DAPT vs OAC+SAP: odds ratio (OR), 0.53; 95% credible interval (CrI), 0.30-0.91) (DAPT vs TT: OR, 0.45; 95% CrI, 0.31-0.64)]. There were no significant differences in major adverse cardiovascular events (MACE), myocardial infarction (MI), cardiovascular (CV) or total survival, stent thrombosis or target vessel revascularization (TVR) amongst the three treatment arms. TT was ranked superior for stroke reduction (SUCRA, 69%) followed by OAC+SAP and DAPT. When traditional analysis was adjusted for randomized data, OAC+SAP was equivalent to TT with regards to stroke (OR, 0.74; 95% confidence interval (CI), 0.38-1.46; p=0.39) and showed significant reduction in MACE and total mortality. CONCLUSION DAPT was found to be the safest and equally effective regimen when compared to TT and OAC+SAP. However this strategy bears considerable risk to patients with high thromboembolic risk. This issue can be encountered by using OAC+SAP as an alternative of TT in patients with intermediate to high stroke risk and intermediate to high bleeding propensity.
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Affiliation(s)
- Safi U Khan
- Guthrie Clinic/Robert Packer Hospital, Sayre, PA, USA.
| | | | | | | | | | - Hammad Rahman
- Guthrie Clinic/Robert Packer Hospital, Sayre, PA, USA
| | - Ahmad N Lone
- Guthrie Clinic/Robert Packer Hospital, Sayre, PA, USA
| | - Edo Kaluski
- Guthrie Clinic/Robert Packer Hospital, Sayre, PA, USA; Rutgers Medical School, Newark, NJ; The Commonwealth Medical College, Scranton, PA
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Barbieri L, Verdoia M, Schaffer A, Suryapranata H, De Luca G. Risk and Benefits of Triple Therapy in Patients Undergoing Coronary Stent Implantation Requiring Oral Anticoagulation: A Meta-Analysis of 16 Studies. Cardiovasc Drugs Ther 2017; 30:611-622. [PMID: 27757726 DOI: 10.1007/s10557-016-6692-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with coronary artery disease who undergo stent implantation and have concomitant indication for long-term oral anticoagulation represent a considerable proportion of the overall population. To date there is still no consensus about the optimal antithrombotic strategy to choose in this kind of patients, due to the difficult balance between an increased risk of bleeding and thromboembolic complications. Therefore, the aim of this study was to perform a meta-analysis to evaluate the risk and benefits of triple antithrombotic therapy versus dual antithrombotic therapy in patients undergoing coronary stent implantation, requiring long-term oral anticoagulation. METHODS We performed formal searches of PubMed, EMBASE, Cochrane central register of controlled trials and major international scientific session abstracts from January 1990 to September 2015 regarding the use of triple antithrombotic therapy (TT) versus dual therapy (DT) in patients undergoing percutaneous coronary stent implantation that required chronic oral anticoagulation. Data regarding study design, inclusion/exclusion criteria, number of patients, and selected endpoints was extracted by 2 investigators. Disagreements were resolved by consensus. RESULTS Sixteen trials with a total of 21716 patients undergoing coronary stent implantation with indication to long term oral anticoagulation, were finally included. A total of 6950 received TT, whereas 14766 received DT alone. The follow-up period ranged from 180 to 730 days. Data regarding mortality were available in 21658 patients (99.7 %). All cause mortality was observed in 10.4 % patients in TT versus 16.3 % in DT (OR [95 % CI] =0.73 [0.66-0.80], p <0.001; p het <0.001). In addition, TT was associated with a reduced incidence of MI (6.4 versus 9.8 %, OR [95 % CI] = 0.74 [0.65-0.84], p < 0.001; phet < 0.001) and ischemic stroke (1.8 versus 3.9 %, OR [95 % CI] = 0.55 [0.45-0.68], p < 0.001; p het = 0.07). As expected, TT was associated with a significant increase in major bleeding events (10.8 versus 8.5 %, OR [95 % CI] = 1.38 [1.25-1.53], p < 0.001; p het = 0.02). By meta regression analysis we found that benefits in mortality with TT were inversely related with the risk of bleedings (beta [95 % CI] = 2.25 (1.55; 2.95), p < 0.00001). The benefits with TT regarding overall mortality, recurrent MI and ischemic stroke were also confirmed in a pre-specified analysis versus DAPT or oral anticoagulation in association with a single antiplatelet agent. CONCLUSION This meta-analysis showed that among patients undergoing coronary stent implantation, requiring chronic OAC, the use of a TT is associated with a significant reduction in overall mortality, recurrent MI and ischemic stroke. As expected, we found a higher incidence of bleedings in patients treated with triple therapy. The benefits in mortality were lost in patients at high-risk for bleedings.
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Affiliation(s)
- Lucia Barbieri
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, C.so Mazzini, 18, 28100, Novara, Italy
| | - Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, C.so Mazzini, 18, 28100, Novara, Italy
| | - Alon Schaffer
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, C.so Mazzini, 18, 28100, Novara, Italy
| | | | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, C.so Mazzini, 18, 28100, Novara, Italy.
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Wang XX, Dong B, Hong B, Gong YQ, Wang W, Wang J, Zhou ZY, Jiang WJ. Long-term prognosis in patients continuing taking antithrombotics after peptic ulcer bleeding. World J Gastroenterol 2017; 23:723-729. [PMID: 28216980 PMCID: PMC5292347 DOI: 10.3748/wjg.v23.i4.723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/13/2016] [Accepted: 12/02/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the long-term prognosis in peptic ulcer patients continuing taking antithrombotics after ulcer bleeding, and to determine the risk factors that influence the prognosis.
METHODS All clinical data of peptic ulcer patients treated from January 1, 2009 to January 1, 2014 were retrospectively collected and analyzed. Patients were divided into either a continuing group to continue taking antithrombotic drugs after ulcer bleeding or a discontinuing group to discontinue antithrombotic drugs. The primary outcome of follow-up in peptic ulcer bleeding patients was recurrent bleeding, and secondary outcome was death or acute cardiovascular disease occurrence. The final date of follow-up was December 31, 2014. Basic demographic data, complications, and disease classifications were analyzed and compared by t- or χ2-test. The number of patients that achieved various outcomes was counted and analyzed statistically. A survival curve was drawn using the Kaplan-Meier method, and the difference was compared using the log-rank test. COX regression multivariate analysis was applied to analyze risk factors for the prognosis of peptic ulcer patients.
RESULTS A total of 167 patients were enrolled into this study. As for the baseline information, differences in age, smoking, alcohol abuse, and acute cardiovascular diseases were statistically significant between the continuing and discontinuing groups (70.8 ± 11.4 vs 62.4 ± 12.0, P < 0.001; 8 (8.2%) vs 15 (21.7%), P < 0.05; 65 (66.3%) vs 13 (18.8%), P < 0.001). At the end of the study, 18 patients had recurrent bleeding and three patients died or had acute cardiovascular disease in the continuing group, while four patients had recurrent bleeding and 15 patients died or had acute cardiovascular disease in the discontinuing group. The differences in these results were statistically significant (P = 0.022, P = 0.000). The Kaplan-Meier survival curve indicated that the incidence of recurrent bleeding was higher in patients in the continuing group, and the risk of death and developing acute cardiovascular disease was higher in patients in the discontinuing group (log-rank test, P = 0.000 for both). Furthermore, COX regression multivariate analysis revealed that the hazard ratio (HR) for recurrent bleeding was 2.986 (95%CI: 067-8.356, P = 0.015) in the continuing group, while HR for death or acute cardiovascular disease was 5.216 (95%CI: 1.035-26.278, P = 0.028).
CONCLUSION After the occurrence of peptic ulcer bleeding, continuing antithrombotics increases the risk of recurrent bleeding events, while discontinuing antithrombotics would increase the risk of death and developing cardiovascular disease. This suggests that clinicians should comprehensively consider the use of antithrombotics after peptic ulcer bleeding.
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Chaudhary N, Bundhun PK, Yan H. Comparing the clinical outcomes in patients with atrial fibrillation receiving dual antiplatelet therapy and patients receiving an addition of an anticoagulant after coronary stent implantation: A systematic review and meta-analysis of observational studies. Medicine (Baltimore) 2016; 95:e5581. [PMID: 27977592 PMCID: PMC5268038 DOI: 10.1097/md.0000000000005581] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Data regarding the clinical outcomes in patients with atrial fibrillation (AF) receiving dual antiplatelet therapy (DAPT) and an anticoagulant in addition to DAPT (DAPT + vitamin K antagonist [VKA]) after coronary stent implantation are still controversial. Therefore, in order to solve this issue, we aim to compare the adverse clinical outcomes in AF patients receiving DAPT and DAPT + VKA after percutaneous coronary intervention and stenting (PCI-S). METHODS Observational studies comparing the adverse clinical outcomes such as major bleeding, major adverse cardiovascular events, stroke, myocardial infarction, all-cause mortality, and stent thrombosis (ST) in AF patients receiving DAPT + VKA therapy, and DAPT after PCI-S have been searched from Medline, EMBASE, and PubMed databases. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on discontinuous variables, and the pooled analyses were performed with RevMan 5.3. RESULTS Eighteen studies consisting of a total of 20,456 patients with AF (7203 patients received DAPT + VKA and 13,253 patients received DAPT after PCI-S) were included in this meta-analysis. At a mean follow-up period of 15 months, the risk of major bleeding was significantly higher in DAPT + VKA group, with OR 0.62 (95% CI 0.50-0.77, P < 0.0001). There was no significant differences in myocardial infarction and major adverse cardiovascular event between DAPT + VKA and DAPT, with OR 1.27 (95% CI 0.92-1.77, P = 0.15) and OR 1.17 (95% CI 0.99-1.39, P = 0.07), respectively. However, the ST, stroke, and all-cause mortality were significantly lower in the DAPT + VKA group, with OR 1.98 (95% CI 1.03-3.81, P = 0.04), 1.59 (95% CI 1.08-2.34, P = 0.02), and 1.41 (95% CI 1.03-1.94, P = 0.03), respectively. CONCLUSION At a mean follow-up period of 15 months, DAPT + VKA was associated with significantly lower risk of stroke, ST, and all-cause mortality in AF patients after PCI-S compared with DAPT group. However, the risk of major bleeding was significantly higher in the DAPT + VKA group.
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High platelet reactivity after P2Y12-inhibition in patients with atrial fibrillation and coronary stenting. J Thromb Thrombolysis 2016; 42:558-65. [PMID: 27387715 DOI: 10.1007/s11239-016-1397-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
High platelet reactivity (HPR) after P2Y12-inhibition in patients undergoing coronary stenting is associated with an increased risk for thromboembolic events and coronary death. So far it is not known how HPR affects the clinical outcome of different treatment strategies in patients with atrial fibrillation (AF) undergoing coronary stenting. In this single centre, observational study the antiplatelet effect of P2Y12-inhibitors in AF patients undergoing coronary stenting was investigated using impedance aggregometry. Patients received either dual antiplatelet therapy (DAPT) or triple therapy (TT). HPR was defined as the ratio of ADP-to TRAP-induced aggregation (r-ADP-agg) ≥50 %. Thromboembolic and bleeding events were assessed within the first 30 days after stenting. Out of 910 screened patients 167 patients were available for the present analysis. HPR was found in 5 of 43 (12 %) patients treated with DAPT and in 18 of 124 (15 %) patients treated with TT. In patients receiving TT, HPR was not a risk factor for thromboembolic events compared to patients with adequate response to P2Y12-inhibitors (6 vs. 8 %, p = 0.712). There was a trend for less bleeding events in patients with HPR compared to r-ADP-agg <50 % in the TT group (0 vs. 16 %, p = 0.077). Our data suggest that HPR after P2Y12-antagonism in patients receiving TT due to AF and coronary stenting might protect from bleeding without increasing thromboembolic risk. Future studies will need to investigate if patients with AF receiving coronary stenting benefit from a reduction of antithrombotic therapy.
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Weisshaar S, Litschauer B, Bucher S, Riesenhuber M, Kapiotis S, Kyrle PA, Wolzt M. The effect of a dual or a triple antithrombotic therapy with apixaban on thrombus formation in vivo and in an ex vivo perfusion chamber model: An open-label, controlled, sequential study. Medicine (Baltimore) 2016; 95:e4145. [PMID: 27399131 PMCID: PMC5058860 DOI: 10.1097/md.0000000000004145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND There is a need to optimize pharmacological treatment in patients with acute coronary syndrome and concomitant atrial fibrillation, in particular with newer antithrombotic medicines. We have therefore studied if dual or triple combination of antithrombotic agents exert similar effects on coagulation activation in an in vivo model in the skin microvasculature and in an ex vivo perfusion chamber. METHODS AND RESULTS Shed blood platelet activation (β-thromboglobulin [β-TG]), thrombin generation (thrombin-antithrombin complex [TAT]) and volume as well as markers of thrombus size (D-dimer) and its platelet content (P-selectin) in a perfusion chamber were studied in a sequential, open-label, parallel group trial in 40 healthy male volunteers (n = 20 per group). Subjects received ticagrelor and apixaban without or with acetylsalicylic acid (ASA). Outcome parameters were assessed at 3 hours after therapy dosing, and at steady-state trough and peak conditions.A triple or dual therapy induced a comparable decrease in shed blood β-TG at 3 hours after therapy dosing but was more pronounced at steady-state conditions with the more intense treatment combination. During both antithrombotic regimens a similarly sustained inhibition in thrombin generation was observed which was accompanied by comparable increases in shed blood volume. In contrast, no treatment effect could be observed in the perfusion chamber experiment. CONCLUSION Ticagrelor and apixaban with or without ASA inhibit platelet activation and thrombin formation in vivo in healthy subjects. Platelet inhibition was greater at steady-state conditions after triple therapy administration.
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Affiliation(s)
- Stefan Weisshaar
- Department of Clinical Pharmacology
- Correspondence: Stefan Weisshaar, Department of Clinical Pharmacology, Medical University of Vienna, Währinger Gürtel, Vienna, Austria (e-mail: )
| | | | | | | | | | - Paul Alexander Kyrle
- Department of Internal Medicine I, Division of Haematology, Medical University of Vienna, Austria
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Faza NN, Mentias A, Parashar A, Chaudhury P, Barakat AF, Agarwal S, Wayangankar S, Ellis SG, Murat Tuzcu E, Kapadia SR. Bleeding complications of triple antithrombotic therapy after percutaneous coronary interventions. Catheter Cardiovasc Interv 2016; 89:E64-E74. [DOI: 10.1002/ccd.26574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 04/22/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Nadeen N. Faza
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - Amgad Mentias
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - Akhil Parashar
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - Pulkit Chaudhury
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - Amr F. Barakat
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - Shikhar Agarwal
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - Siddharth Wayangankar
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - Stephen G. Ellis
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - E. Murat Tuzcu
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine; Heart and Vascular Institute, Cleveland Clinic; Ohio
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Triple antithrombotic therapy versus dual antiplatelet therapy in patients with atrial fibrillation undergoing drug-eluting stent implantation. Coron Artery Dis 2016; 26:372-80. [PMID: 25768244 DOI: 10.1097/mca.0000000000000242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The optimal antithrombotic regimen in patients with atrial fibrillation (AF) undergoing drug-eluting stent (DES) implantation for complex coronary artery disease is unclear. We compared the net clinical outcomes of triple antithrombotic therapy (TAT; aspirin, thienopyridine, and warfarin) and dual antiplatelet therapy (DAPT; aspirin and thienopyridine) in AF patients who had undergone DES implantation. METHODS A total of 367 patients were enrolled and analyzed retrospectively; 131 patients (35.7%) received TAT and 236 patients (64.3%) received DAPT. DAPT and warfarin were maintained for a minimum of 12 and 24 months, respectively. The primary endpoint was the 2-year net clinical outcomes, a composite of major bleeding and major adverse cardiac and cerebral events (MACCE). Propensity score-matching analysis was carried out in 99 patient pairs. RESULTS The 2-year net clinical outcomes of the TAT group were worse than those of the DAPT group (34.3 vs. 21.1%, P=0.006), which was mainly due to the higher incidence of major bleeding (16.7 vs. 4.6%, P<0.001), without any significant increase in MACCE (22.1 vs. 17.7%, P=0.313). In the multivariate analysis, TAT was an independent predictor of worse net clinical outcomes (odds ratio 1.63, 95% confidence interval 1.06-2.50) and major bleeding (odds ratio 3.54, 95% confidence interval 1.65-7.58). After propensity score matching, the TAT group still had worse net clinical outcomes and a higher incidence of major bleeding compared with the DAPT group. CONCLUSION In AF patients undergoing DES implantation, prolonged administration of TAT may be harmful due to the substantial increase in the risk for major bleeding without any reduction in MACCE.
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Shah Z, Masoomi R, Tadros P. Managing Antiplatelet Therapy and Anticoagulants in Patients with Coronary Artery Disease and Atrial Fibrillation. J Atr Fibrillation 2015; 8:1318. [PMID: 27957230 DOI: 10.4022/jafib.1318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 09/09/2015] [Accepted: 10/27/2015] [Indexed: 01/15/2023]
Abstract
Oral anticoagulation (OAC) is essential in patients with atrial fibrillation (AF). Interestingly coronary artery disease coexists in 20-30% of these patients.[1,2] Balancing the risk of bleeding and thromboembolism is very important for the management of patients on OAC, especially than when such patients require percutaneous coronary intervention (PCI). Lack of data and clear societal guidelines for peri-procedural and post-procedural management of anticoagulated patients has resulted in diverse clinical practices among clinicians, hospitals, and countries. Furthermore with expanding number of available oral antiplatelet and anticoagulant agents, the uncertainty regarding optimal combination therapy in this growing pool of the patients with overlapping clinical indications is also growing. Given the high proportion of patients with atherothrombosis and requiring OAC for conditions particularly like AF, it is important that physicians are aware of the clinical implications and management of these overlapping syndromes. In this article we discuss; this evolving dilemma of peri-procedural and post-procedural management of anticoagulated patient's, burden of the disease, available data, risk factors that could identify high risk patients and propose a well-balanced management strategy.
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Affiliation(s)
- Zubair Shah
- Division of Cardiovascular Diseases, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS
| | - Reza Masoomi
- Division of Cardiovascular Diseases, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS
| | - Peter Tadros
- Division of Cardiovascular Diseases, Mid America Cardiology, University of Kansas Hospital and Medical Center, Kansas City, KS
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Liu J, Fan M, Zhao J, Zhao B, Zhang C, Liu C, Dong Y. Efficacy and safety of antithrombotic regimens after coronary intervention in patients on oral anticoagulation: Traditional and Bayesian meta-analysis of clinical trials. Int J Cardiol 2015; 205:89-96. [PMID: 26724753 DOI: 10.1016/j.ijcard.2015.12.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 12/12/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To perform a systematic review and meta-analysis to assess the efficacy and safety of diverse antithrombotic regimens in patients on long-term anticoagulation after percutaneous coronary intervention (PCI). METHODS After searching electronic database (up to 27 June 2015), we included trials comparing dual antiplatelet therapy (aspirin plus clopidogrel), oral anticoagulant (OAC) plus clopidogrel, OAC plus aspirin, or triple therapy (OAC with clopidogrel and aspirin). Efficacy outcomes were major adverse cardiovascular event (MACE), ischemic stroke, myocardial infarction (MI), and all-cause mortality; safety outcomes included major bleeding and any bleeding. We conducted both traditional and Bayesian network meta-analysis, computing pooled odds ratio (OR) with 95% confidence intervals (CI) to compare diverse antithrombotic therapies simultaneously. RESULTS Eighteen trials were included in the quantitative analysis. OAC plus clopidogrel and triple therapy were associated with a lower risk of MACE, ischemic stroke, MI and all-cause mortality compared with dual antiplatelet or OAC plus aspirin regimens. OAC plus clopidogrel was ranked the most efficacious option without an increase in bleeding episodes. However, triple therapy improved the efficacy outcomes at the expense of increasing hemorrhage. For the initial short-term outcomes, OAC plus clopidogrel inconclusively reduced the risk of MACE and had a significantly lower risk of any bleeding. CONCLUSIONS OAC plus clopidogrel may be the optimal antithrombotic therapy in patients on oral anticoagulation undergoing PCI, which has equal or better efficacy outcomes without increasing the rates of bleeding episodes. Moreover, we found initial triple therapy to be unnecessary as it increased the risk of bleeding.
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Affiliation(s)
- Jian Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Meida Fan
- Department of Rheumatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Jingjing Zhao
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Bingcheng Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Chongyu Zhang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.
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Čolić MD, Čalija BM, Milosavljević BM, Grdinić AG, Angelkov LG, Sagić DŽ, Kruzliak P, Marinković JM, Babić RM, Mrdović IB. Low On-Treatment Platelet Reactivity Predicts Long-Term Risk of Bleeding After Elective PCI. J Interv Cardiol 2015; 28:531-43. [PMID: 26643001 DOI: 10.1111/joic.12251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Bleeding after percutaneous coronary interventions (PCI) is an important complication with impact on prognosis. AIM To evaluate the predictive value of enhanced platelet responsiveness to dual antiplatelet therapy with aspirin and clopidogrel, for bleeding, after elective PCI. METHODS AND RESULTS We performed multiple electrode aggregometry (MAE) platelet functional tests induced by arachidonic acid (ASPI) and adenosine-diphosphate (ADP) before PCI, and 24 hours after PCI, in 481 elective PCI patients who were followed-up for an average of 15.34 ± 7.19 months. Primary end point was the occurrence of any bleeding, while ischemic major adverse cardiovascular event (MACE) was a secondary endpoint. The incidence of total, BARC ≤ 2, and BARC ≥ 3 bleeding, according to BARC classification, was 19, 18, and 1%, respectively. Groups with any, and BARC ≤ 2 bleeding, had a lower average value of MAE ADP test after 24 hours, compared to the group without bleeding: 45.30 ± 18.63 U versus 50.99 ± 19.01 U; P = 0.005; and 45.75 ± 18.96 U versus 50.99 ± 18.99 U; P = 0.01; respectively. Female gender (HR 2.11; CI 1.37-3.25; P = 0.001), previous myocardial infarction (HR 0.56; CI 0.37-0.85; P = 0.006), lower body mass (HR 0.78; CI 0.62-0.98; P = 0.03), and MAE ADP test after 24 hours (HR 0.75; CI 0.61-0.93; P = 0.009) were the independent predictors for any bleeding by Cox univariate analysis. After adjustment, MAE ADP test after 24 hours, was the only independent predictor for any (HR 0.7; CI 0.56-0.87; P = 0.002), and BARC ≤ 2 (HR 0.71; CI 0.56-0.89; P = 0.003) bleeding, by Cox multivariate analysis. CONCLUSION MAE ADP test before and after PCI, was associated with any, and BARC ≤ 2 bleeding after elective PCI.
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Affiliation(s)
| | | | | | | | | | | | - Peter Kruzliak
- International Clinical Research Center, St. Anne's University Hospital and Masaryk University, Brno, Czech Republic
| | - Jelena M Marinković
- School of Medicine, Institute for Medical Statistics and Informatics, University of Belgrade, Belgrade, Serbia
| | - Rade M Babić
- Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Igor B Mrdović
- Urgent Cardiology, Emergency Hospital, Clinical Centre of Serbia, Belgrade, Serbia
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Bavishi C, Koulova A, Bangalore S, Sawant A, Chatterjee S, Ather S, Valencia J, Sarafoff N, Rubboli A, Airaksinen JK, Lip GYH, Tamis-Holland JE. Evaluation of the efficacy and safety of dual antiplatelet therapy with or without warfarin in patients with a clinical indication for DAPT and chronic anticoagulation: A meta-analysis of observational studies. Catheter Cardiovasc Interv 2015; 88:E12-22. [PMID: 26354765 DOI: 10.1002/ccd.26234] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/27/2015] [Accepted: 08/24/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of dual antiplatelet therapy (DAPT) and triple therapy (TT, dual antiplatelet plus warfarin) in patients with myocardial infarction (MI) or PCI with stenting (PCI-S) who also require chronic oral anticoagulation. BACKGROUND Recommendations for the optimal antiplatelet/anticoagulant treatment regimen for patients undergoing PCI-S or MI who also require oral anticoagulation are largely based on evidence from observational studies and expert opinions. METHODS A systematic search was performed for studies comparing TT vs. DAPT in patients post PCI-S or MI and requiring chronic anticoagulation. Primary outcome was all-cause mortality. Secondary outcomes were ischemic stroke, major bleeding, MI, and stent thrombosis. Pooled relative risks (RR) were calculated using random effects model. RESULTS A total of 17 studies were included, with 14,921 patients [TT: 5,819(39%) and DAPT: 9,102(61%)] and a mean follow-up of 1.6 years. The majority of patients required oral anticoagulation for atrial fibrillation. Compared to DAPT, patients treated with TT had no significant difference in all-cause mortality [RR: 0.81, 95% confidence interval (CI): 0.61-1.08, P = 0.15], MI [RR 0.74, 95% CI: 0.51-1.06, P = 0.10], and stent thrombosis [RR 0.67, 95% CI: 0.35-1.30, P = 0.24]. Patients treated with TT had significantly increased risk of major bleeding [RR 1.20, 95% CI: 1.03-1.39, P = 0.02], whereas the risk for ischemic stroke was significantly lower [RR 0.59, 95% CI: 0.38-0.92, P = 0.02]. CONCLUSIONS All-cause mortality appears similar in patients treated with TT or DAPT although TT was associated with higher rates of major bleeding and a lower risk for ischemic stroke. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Chirag Bavishi
- Mount Sinai St. Luke's and Roosevelt Hospitals, New York, New York
| | - Anna Koulova
- Mount Sinai St. Luke's and Roosevelt Hospitals, New York, New York
| | | | - Ashwin Sawant
- Mount Sinai St. Luke's and Roosevelt Hospitals, New York, New York
| | | | - Sameer Ather
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Jose Valencia
- General Hospital University of Alicante, Alicante, Spain
| | | | - Andrea Rubboli
- Division of Cardiology, Ospedale Maggiore, Bologna, Italy
| | - Juhani K Airaksinen
- Turku University Hospital and University of Turku Heart Center, Turku, Finland
| | - Gregory Y H Lip
- Department of Clinical Medicine, University of Birmingham, Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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Huo Y, Lee SWL, Sawhney JPS, Kim HS, Krittayaphong R, Nhan VT, Alonso-Garcia A, Han YL, Ge J, Chin CT, Ong TK, Jan S, Itoh Y, Vega AM, Pocock S. Rationale, Design, and Baseline Characteristics of the EPICOR Asia Study (Long-tErm follow-uP of antithrombotic management patterns In Acute CORonary Syndrome patients in Asia). Clin Cardiol 2015. [PMID: 26206158 DOI: 10.1002/clc.22431] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In-hospital and postdischarge mortality for acute coronary syndromes (ACS) vary across Asia and remain generally poorer than globally. The relationship between real-life antithrombotic management patterns (AMPs) and ACS-related outcomes in Asia is unclear. METHODS EPICOR Asia (Long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients in Asia) (NCT01361386) is a prospective, multinational, observational study of patients discharged after hospitalization for an ACS, with 2-year follow-up. The aim is to describe short- and long-term (up to 2 years post-index event) AMPs in patients hospitalized for ACS and to record clinical outcomes, healthcare resource use, and self-reported health status. Pre- and in-hospital management, AMPs, and associated outcomes, with particular focus on ischemic and bleeding events, will be recorded during the 2-year follow up. RESULTS Between June 2011 and May 2012, 13 005 patients were enrolled. From these, 12 922 patients surviving an ACS (6616 with STEMI, 2570 with NSTEMI, and 3736 with UA) were eligible for inclusion from 219 hospitals across 8 countries and regions in Asia: China (n = 8214), Hong Kong (n = 177), India (n = 2468), Malaysia (n = 100), Singapore (n = 93), South Korea (n = 705), Thailand (n = 957), and Vietnam (n = 208). CONCLUSIONS EPICOR Asia will provide information regarding clinical management and AMPs for ACS patients in Asia. Impact of AMPs on clinical outcomes, healthcare resource use, and self-reported health status both during hospitalization and up to 2 years after discharge will also be described.
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Affiliation(s)
- Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Stephen W-L Lee
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | | | - Hyo-Soo Kim
- Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | | | - Vo T Nhan
- Department of Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Angeles Alonso-Garcia
- Cardiovascular Science Research Centre, St. George's University of London, London, United Kingdom
| | - Ya Ling Han
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Shanghai, China
| | - Chee Tang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore and Duke-NUS Graduate Medical School, Singapore
| | - Tiong K Ong
- Department of Cardiology, Sarawak General Hospital, Kuching, Malaysia
| | - Stephen Jan
- Health Economics Program, The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Yohji Itoh
- Clinical Science Division, AstraZeneca, Osaka, Japan
| | - Ana Maria Vega
- Observational Research Centre, Global Medical Affairs, AstraZeneca, Madrid, Spain
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Chen CF, Chen B, Zhu J, Xu YZ. Antithrombotic therapy after percutaneous coronary intervention in patients requiring oral anticoagulant treatment. A meta-analysis. Herz 2015; 40:1070-83. [PMID: 26135462 DOI: 10.1007/s00059-015-4325-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 04/30/2015] [Accepted: 05/13/2015] [Indexed: 01/01/2023]
Abstract
AIM The aim of this meta-analysis was to evaluate the benefits and risks of triple therapy (TT) compared with dual therapy (DT) for patients with an indication for anticoagulation who had undergone percutaneous coronary intervention. BACKGROUND An increasing number of patients undergoing percutaneous coronary intervention have atrial fibrillation or other indications for oral anticoagulants. For these patients, TT (oral anticoagulants plus aspirin and clopidogrel) is indicated, but this type of treatment increases the risk of bleeding. Thus, it remains controversial whether these patients can benefit more from TT. METHODS We identified 23 clinical trials that compared TT with DT (aspirin and clopidogrel or oral anticoagulants plus a single antiplatelet drug) after percutaneous coronary intervention in patients undergoing oral anticoagulant (OAC) treatment. The follow-up period ranged from 1 month to 25 months. Two coauthors independently recorded the data on interventions and on the occurrence of major adverse cardiac events (MACE), all-cause death, and major bleeding events. RESULTS The 23 clinical trials comprised 22,212 participants. Our analysis was feasible because the baseline characteristics and grouping criteria were similar in all groups. The results indicated that TT was more efficacious than DT [dual antiplatelet (DAPT) or OAC + single antiplatelet] in reducing MACE/stroke (RR = 0.76, 95 % CI: 0.70-0.83; p < 0.00001 and RR = 0.67, 95 % CI: 0.59-0.75; p < 0.00001, respectively) There was a significant reduction in all-cause death in the TT regimen compared with the DT regimen (RR = 0.64, 95 % CI: 0.56-0.73; p < 0.00001 and RR = 0.48, 95 % CI: 0.39-0.58; p < 0.00001, respectively). In a subgroup analysis without retrospective studies, we found that there was no significant difference between TT and DT with regard to MACE/stroke (RR = 1.06, 95 % CI: 0.88-1.27; p = 0.54 and RR = 0.95, 95 % CI: 0.79-1.14; p = 0.58, respectively) and all-cause death (RR = 0.84, 95 % CI: 0.63-1.12; p = 0.24 and RR = 1.13, 95 % CI: 0.78-1.64; p = 0.51, respectively). We also found that TT significantly increased the risk of major bleeding compared with DAPT (RR = 1.36; 95 % CI: 1.17-1.58; p < 0.0001). However, there was no difference between TT and OAC + single antiplatelet agent (RR = 0.96; 95 % CI: 0.75-1.21; p = 0.71). Finally, in the comparison between TT and OAC + clopidogrel, there were no differences in major bleeding events, MACE and stroke, and all-cause death. CONCLUSION Our analysis found no statistically significant difference between TT and DT with regard to all-cause death and MACE/stroke risk. At the same time, the available data demonstrated that TT increased the risk of major bleeding. If the international normalized ratio is in the target range, the risk of bleeding may be lowered. The data from Asian countries were limited, and therefore we could not assess the difference between TT and DT in Asian populations. Finally,on the basis of our analysis, we do not recommend TT as conventional treatment for patients taking OACs and undergoing percutaneous coronary intervention.
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Affiliation(s)
- Chao-Feng Chen
- The Affiliated Hangzhou Hospital, Nanjing Medical University, Hang Zhou, Zhe Jiang Province, China
| | - Bin Chen
- The Affiliated Hangzhou Hospital, Nanjing Medical University, Hang Zhou, Zhe Jiang Province, China
| | - Jue Zhu
- The Affiliated Hangzhou Hospital, Nanjing Medical University, Hang Zhou, Zhe Jiang Province, China
| | - Yi-Zhou Xu
- The Affiliated Hangzhou Hospital, Nanjing Medical University, Hang Zhou, Zhe Jiang Province, China.
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Huang AL, Murphy JC, Shaw E, Kozor R, Yan W, Loxton A, Soo Hoo SY, Figtree GA, Rasmussen HH, Hansen PS, Nelson GI, Bhindi R, Ward MR. Routine aspiration thrombectomy improves the diagnosis and management of embolic myocardial infarction. Catheter Cardiovasc Interv 2015; 87:642-7. [DOI: 10.1002/ccd.26047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 05/06/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Alex L Huang
- Royal North Shore Hospital; St Leonards Australia
| | | | | | | | - Warren Yan
- Royal North Shore Hospital; St Leonards Australia
| | - Anne Loxton
- Royal North Shore Hospital; St Leonards Australia
| | | | - Gemma A. Figtree
- Royal North Shore Hospital; St Leonards Australia
- University of Sydney; Sydney Australia
| | - Helge H. Rasmussen
- Royal North Shore Hospital; St Leonards Australia
- University of Sydney; Sydney Australia
| | - Peter S. Hansen
- Royal North Shore Hospital; St Leonards Australia
- University of Sydney; Sydney Australia
| | - Gregory I.C. Nelson
- Royal North Shore Hospital; St Leonards Australia
- University of Sydney; Sydney Australia
| | - Ravinay Bhindi
- Royal North Shore Hospital; St Leonards Australia
- University of Sydney; Sydney Australia
| | - Michael R. Ward
- Royal North Shore Hospital; St Leonards Australia
- University of Sydney; Sydney Australia
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Gao F, Shen H, Wang ZJ, Yang SW, Liu XL, Zhou YJ. Rationale and design of the RT-AF study: Combination of rivaroxaban and ticagrelor in patients with atrial fibrillation and coronary artery disease undergoing percutaneous coronary intervention. Contemp Clin Trials 2015; 43:129-32. [PMID: 26003433 DOI: 10.1016/j.cct.2015.05.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/14/2015] [Accepted: 05/17/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Optimal antithrombotic strategy for patients with concomitant coronary artery disease and atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is still controversial, and the role of novel antithrombotic agents has nerve been tested. Therefore, the aim of this study is to evaluate and overall safety and efficacy profile of the combination of rivaroxaban and ticagrelor in this particular population. DESIGN The RT-AF study is an open-label, randomized, active-controlled, multicenter clinical trial with up to 420 subjects enrolled in 5 centers. Eligible patients, who have a history or new onset paroxysmal, persistent, or permanent non-valvular AF, referred to the study centers with indications for PCI will be randomly assigned to receive triple therapy (including warfarin, clopidogrel and aspirin) or dual therapy (rivaroxaban and ticagrelor). All subjects will have clinical follow-up at discharge, at 30 days, 6 months and 12 months. The primary end point is major or clinically relevant non-major bleeding events at 12 months. The major secondary end point is the composite efficacy outcome of death, myocardial infarction, stent thrombosis and ischemic stroke. CONCLUSION The study will be sufficiently powered to provide data primarily regarding the safety of dual therapy with rivaroxaban and ticagrelor over the traditional triple therapy in patients with AF undergoing PCI at 12 months. It will also provide important information regarding the efficacy of the two different antithrombotic regimens. (ClinicalTrials.gov identifier: NCT02334254).
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Affiliation(s)
- Fei Gao
- Department of Cardiology, An Zhen Hospital, Capital Medical University, Beijing, China
| | - Hua Shen
- Department of Cardiology, An Zhen Hospital, Capital Medical University, Beijing, China
| | - Zhi Jian Wang
- Department of Cardiology, An Zhen Hospital, Capital Medical University, Beijing, China
| | - Shi Wei Yang
- Department of Cardiology, An Zhen Hospital, Capital Medical University, Beijing, China
| | - Xiao Li Liu
- Department of Cardiology, An Zhen Hospital, Capital Medical University, Beijing, China
| | - Yu Jie Zhou
- Department of Cardiology, An Zhen Hospital, Capital Medical University, Beijing, China.
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Gao XF, Chen Y, Fan ZG, Jiang XM, Wang ZM, Li B, Mao WX, Zhang JJ, Chen SL. Antithrombotic Regimens for Patients Taking Oral Anticoagulation After Coronary Intervention: A Meta-analysis of 16 Clinical Trials and 9,185 Patients. Clin Cardiol 2015; 38:499-509. [PMID: 25963316 PMCID: PMC4744725 DOI: 10.1002/clc.22411] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/06/2015] [Indexed: 12/04/2022] Open
Abstract
The optimal antithrombotic regimen remains controversial in patients taking oral anticoagulation (OAC) undergoing coronary stenting. This study sought to compare efficacy and safety outcomes of triple therapy (OAC, aspirin, and clopidogrel) vs dual therapy (clopidogrel with aspirin or OAC) in these patients. We hypothesize OAC plus clopidogrel could be the optimal regimen for patients with indications for OAC receiving stent implantation. Medline, the Cochrane Library, and other Internet sources were searched for clinical trials comparing the efficacy and safety of triple vs dual therapy for patients taking OAC after coronary stenting. Sixteen eligible trials including 9185 patients were identified. The risks of major adverse cardiac events (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 0.82‐1.39, P = 0.65), all‐cause mortality (OR: 0.98, 95% CI: 0.76‐1.27, P = 0.89), myocardial infarction (OR: 1.01, 95% CI: 0.77‐1.31, P = 0.97), and stent thrombosis (OR: 0.91, 95% CI: 0.49‐1.69, P = 0.75) were similar between triple and dual therapy. Compared with dual therapy, triple therapy was associated with a reduced risk of ischemic stroke (OR: 0.57, 95% CI: 0.35‐0.94, P = 0.03) but with higher major bleeding (OR: 1.52, 95% CI: 1.11‐2.10, P = 0.01) and minor bleeding (OR: 1.59, 95% CI: 1.05‐2.42, P = 0.03). Subgroup analysis indicated there were similar ischemic stroke and major bleeding outcomes between triple therapy and therapy with OAC plus clopidogrel. Treatment with OAC and clopidogrel was associated with similar efficacy and safety outcomes compared with triple therapy. Triple therapy could be replaced by OAC plus clopidogrel without any concern about additional risk of thrombotic events.
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Affiliation(s)
- Xiao-Fei Gao
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.,Department of Cardiology, Nanjing Heart Center, Nanjing, China
| | - Yan Chen
- Department of Neurology, Drum Tower Hospital, Nanjing Medical University, Nanjing, China
| | - Zhong-Guo Fan
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiao-Min Jiang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhi-Mei Wang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Bing Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wen-Xing Mao
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jun-Jie Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.,Department of Cardiology, Nanjing Heart Center, Nanjing, China
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.,Department of Cardiology, Nanjing Heart Center, Nanjing, China
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D'Ascenzo F, Taha S, Moretti C, Omedè P, Grossomarra W, Persson J, Lamberts M, Dewilde W, Rubboli A, Fernández S, Cerrato E, Meynet I, Ballocca F, Barbero U, Quadri G, Giordana F, Conrotto F, Capodanno D, DiNicolantonio J, Bangalore S, Reed M, Meier P, Zoccai G, Gaita F. Meta-analysis of randomized controlled trials and adjusted observational results of use of clopidogrel, aspirin, and oral anticoagulants in patients undergoing percutaneous coronary intervention. Am J Cardiol 2015; 115:1185-93. [PMID: 25799015 DOI: 10.1016/j.amjcard.2015.02.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/03/2015] [Accepted: 02/03/2015] [Indexed: 02/05/2023]
Abstract
The optimal antiaggregant therapy after coronary stenting in patients receiving oral anticoagulants (OACs) is currently debated. MEDLINE and Cochrane Library were searched for studies reporting outcomes of patients who underwent PCI and who were on triple therapy (TT) or dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel or dual therapy (DT) with OAC and clopidogrel. Major bleeding was the primary end point, whereas all-cause death, myocardial infarction (MI), stent thrombosis, and stroke were secondary ones. Results were reported for all studies and separately for those deriving from randomized controlled trials or multivariate analysis. In 9 studies, 1,317 patients were treated with DAPT and 1,547 with TT. DAPT offered a significant reduction of major bleeding at 1 year for overall studies and for the subset of observational works providing adjusted data (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.39 to 0.68, I2 60% and OR 0.36, 95% CI 0.28 to 0.46) compared to TT. No increased risk of major adverse cardiac events (MACE: death, MI, stroke, and stent thrombosis) was reported (OR 0.71, 95% CI 0.46 to 1.08), although not deriving from randomized controlled trials or multivariate analysis. Six studies tested OAC and clopidogrel (1,263 patients) versus OAC, aspirin, and clopidogrel (3,055 patients) with a significant reduction of bleeding (OR 0.79, 95% CI 0.64 to 0.98), without affecting rates of death, MI, stroke, and stent thrombosis (OR 0.90, 95% CI 0.69 to 1.23) also when including clinical data from randomized controlled trials or multivariate analysis. In conclusion, compared to TT, both aspirin and clopidogrel and clopidogrel and OAC reduce bleeding. No difference in major adverse cardiac events is present for clopidogrel and OAC, whereas only low-grade evidence is present for aspirin and clopidogrel.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Salma Taha
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy; Department of Cardiology, Assiut University Hospital, Assiut, Egypt.
| | - Claudio Moretti
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Pierluigi Omedè
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Walter Grossomarra
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Jonas Persson
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital Gentofte, Denmark
| | - Willem Dewilde
- Department of Cardiology, Twee Steden Hospital, Tilburg, Netherlands
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy
| | - Sergio Fernández
- Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Enrico Cerrato
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Ilaria Meynet
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Flavia Ballocca
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Umberto Barbero
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Giorgio Quadri
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Francesca Giordana
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Davide Capodanno
- Department of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
| | | | - Sripal Bangalore
- Department of Medicine, Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Matthew Reed
- Emergency Department, Royal infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Pascal Meier
- The Heart Hospital, University College London Hospital, London, United Kingdom
| | - Giuseppe Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome, Latina, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy
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Major bleeding complications related to combined antithrombotic therapy in atrial fibrillation patients 12 months after coronary artery stenting. J Cardiol 2015; 65:197-202. [DOI: 10.1016/j.jjcc.2014.08.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 08/21/2014] [Accepted: 08/30/2014] [Indexed: 11/22/2022]
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Gallagher S, Archbold RA. Percutaneous Coronary Intervention in Patients Who Have an Indication for Oral Anticoagulation - an Evidence-based Approach to Antithrombotic Therapy. Interv Cardiol 2015; 10:16-21. [PMID: 29588668 DOI: 10.15420/icr.2015.10.1.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) is required following percutaneous coronary intervention (PCI) to prevent stent thrombosis. The optimal antithrombotic therapy following PCI for patients with an indication for long-term oral anticoagulation (OAC) is uncertain. DAPT and OAC, a combination known as 'triple therapy', reduces cardiovascular event rates but is associated with a substantial risk of bleeding. Recent data suggest that the duration of DAPT (and thereby triple therapy in those who also require OAC) can be limited to 1-3 months following new-generation drug-eluting stent deployment, and that aspirin may be omitted from triple therapy, without increasing the rate of ischaemic cardiovascular events. The increasing use of non-vitamin K antagonist oral anticoagulants and new antiplatelet agents (prasugrel and ticagrelor) has further complicated antithrombotic prescribing. This article aims to provide a summary of the evidence regarding antithrombotic therapy after PCI in patients who have an indication for OAC and to provide a framework to aid clinical decision-making in this area.
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Affiliation(s)
- Sean Gallagher
- Department of Cardiology, Barts Health NHS Trust.,NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London, UK
| | - R Andrew Archbold
- Department of Cardiology, Barts Health NHS Trust.,NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London, UK
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Antithrombotic therapy in patients with acute coronary syndrome in the intermountain heart collaborative study. Cardiol Res Pract 2015; 2015:270508. [PMID: 25632367 PMCID: PMC4302371 DOI: 10.1155/2015/270508] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 12/01/2014] [Accepted: 12/16/2014] [Indexed: 11/18/2022] Open
Abstract
Objective. To determine factors associated with single antiplatelet (SAP) or dual antiplatelet (DAP) therapy and anticoagulants (AC) use in hospital and after discharge among patients with acute coronary syndrome (ACS). Methods. We evaluated 5,294 ACS patients in the Intermountain Heart Collaborative Study from 2004 to 2009. Multivariable logistic regressions were used to determine predictors of AC or AP use. Results. In hospital, 99% received an AC, 79% DAP, and 19% SAP; 78% had DAP + AC. Coronary stents were the strongest predictors of DAP use in hospital compared to SAP (P < 0.001). After discharge, 77% received DAP, 20% SAP, and 9% AC; 5% had DAP + AC. DAP compared to SAP was less likely for patients on AC (odds ratio [OR] = 0.30, P < 0.0001) after discharge. Placement of a stent increased the likelihood of DAP (bare metal: OR = 54.8, P < 0.0001; drug eluting: OR = 59.4, P < 0.0001). 923 had atrial fibrillation and 337 had a history of venous thromboembolism; these patients had increased use of AC (29% and 40%, resp.). Conclusion. While in-hospital use of AC was nearly universal, postdischarge AC use was rare. Concern for providing the best antithrombotic therapy, while maintaining an acceptable bleeding risk, may explain the selection decisions.
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Rationale and design of MANJUSRI trial: a randomized, open-label, active-controlled multicenter study to evaluate the safety of combined therapy with ticagrelor and warfarin in AF subjects after PCI-eS. Contemp Clin Trials 2014; 40:166-71. [PMID: 25513965 DOI: 10.1016/j.cct.2014.12.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 12/04/2014] [Accepted: 12/06/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Long-term oral anticoagulant treatment is obligatory in patients with atrial fibrillation (AF, score of CHA₂DS₂VASc≥2). When these patients undergo percutaneous coronary intervention with a drug-eluting stent (PCI-eS), there is also an indication for aspirin and clopidogrel treatment, according to the ESC Guidelines. However, triple therapy has been known to increase the risk of bleeding complications. Unfortunately, there is little prospective data available to resolve this issue. Therefore, it is imperative that an optimal therapy for AF patients with indications of both anticoagulation and antiplatelet intervention to prevent thrombotic complications without increasing the risk of bleeding is found. OBJECTIVES This prospective, randomized, multicenter study is going to assess the hypothesis that in persistent or permanent AF patients (score of CHA₂DS₂VASc≥2) after PCI-eS, the combination therapy of oral anticoagulation (warfarin) and ticagrelor (90 mg/bid) could reduce the risk of bleeding events. DESIGN A multicenter, active-controlled, open-label, randomized trial is to be performed to evaluate dual antithrombotic therapy (ticagrelor+warfarin) in persistent or permanent AF patients (score of CHA₂DS₂VASc≥2) after PCI-eS versus the combination of triple antithrombosis (clopidogrel+aspirin+warfarin). The primary endpoint is the overall bleeding up to 6 months, according to TIMI criteria and classifications. The secondary endpoints are the major bleeding events up to 6 months, according to TIMI criteria. The sample size is estimated at 296. CONCLUSION This study is intended to provide information about the safety characteristics of warfarin and ticagrelor in persistent or permanent AF patients after PCI-eS. No prospective randomized study has been conducted on the issue of antithrombotic therapy using warfarin and ticagrelor in these patients. Therefore, the MANJUSRI trial will help to explore and determine a new potential therapeutic regimen for AF patients after PCI-eS. TRIAL REGISTRATION Clinical Trials.gov # NCT02206815, registered July 30, 2014.
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40
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Lee H, Leem CS, Lee JH, Lee CT, Cho YJ. Successful removal of endobronchial blood clots using bronchoscopic cryotherapy at bedside in the intensive care unit. Tuberc Respir Dis (Seoul) 2014; 77:193-6. [PMID: 25368667 PMCID: PMC4217037 DOI: 10.4046/trd.2014.77.4.193] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 06/10/2014] [Accepted: 06/25/2014] [Indexed: 11/28/2022] Open
Abstract
Acute airway obstruction after hemoptysis occurs due to the presence of blood clots. These conditions may result in life-threatening ventilation impairment. We report a case of obstruction of the large airway by endobronchial blood clots which were removed using bronchoscopic cryotherapy at the bedside of intensive care unit. A 66-year-old female with endometrial cancer who had undergone chemotherapy, was admitted to the intensive care unit due to neutropenic fever. During mechanical ventilation, the minute ventilation dropped to inadequately low levels and chest radiography showed complete opacification of the left hemithorax. Flexible bronchoscopy revealed large blood clots obstructing the proximal left main bronchus. After unsuccessful attempts to remove the clots with bronchial lavage and forceps extraction, blood clots were removed using bronchoscopic cryotherapy. This report shows that cryotherapy via flexible bronchoscopy at the bedside in the intensive of intensive care unit is a simple and effective alternative for the removal of endobronchial blood clots.
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Affiliation(s)
- Hongyeul Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Cho Sun Leem
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Vardi M, Debidda M, Bhatt DL, Mauri L, Cannon CP. Evolving antithrombotic strategies in patients with atrial fibrillation undergoing percutaneous coronary intervention: results from a survey among US cardiologists. Clin Cardiol 2014; 37:103-7. [PMID: 24672813 DOI: 10.1002/clc.22226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Many patients treated with oral anticoagulants for atrial fibrillation undergo percutaneous stent implantation, where dual antiplatelet therapy (DAPT) is also recommended. The current evidence to support triple oral antithrombotic therapy (TOAT) in these patients is limited, and new strategies are being discussed to optimize outcomes. HYPOTHESIS There will be variation in antithrombotic strategies in patients with atrial fibrillation needing stenting. METHODS We surveyed US-based cardiologists serving as clinical investigators in academic sites and posted an online "question of the month" on cardiosource.org. RESULTS Seventy-five (10.7%) responses were received to the email survey and 119 to the online question. Bare-metal stenting (BMS) was a priori preferred over drug-eluting stenting (DES) for 50.6% of patients. Only 8.8% of the responders chose newer anticoagulants in addition to DAPT as the preferred oral anticoagulant. For duration of TOAT, 79.4% of physicians recommended stopping DAPT at 1 month when BMS was used in patients presenting without acute coronary syndrome (ACS) vs 57.4% in patients with ACS. In patients implanted with a DES, 73.5% and 76.5% preferred stopping DAPT at 6 to 12 months (no ACS vs ACS, respectively). When asked which of the 2 antiplatelet agents they would recommend stopping after the above durations, 50% chose to quit aspirin. CONCLUSIONS The survey highlights an interest in the new strategy of dropping aspirin, but the lack of concrete evidence triggers undesired diversity in clinical approaches. High-quality data on the efficacy and safety of such interventions are needed to further consolidate these approaches.
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Mallikarjuna Rao Edupuganti M, Marmagkiolis K, Cilingiroglu M, Uretsky BF, Hakeem A. Optimizing selection of antithrombotic therapy in patients requiring PCI and long term anticoagulation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:414-20. [PMID: 25204491 DOI: 10.1016/j.carrev.2014.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 07/23/2014] [Indexed: 10/25/2022]
Abstract
There remains clinical equipoise in the appropriate selection of antiplatelet therapy for the patient on long-term anticoagulation requiring percutaneous coronary intervention. Since most of these patients represent an increasingly aging population, the significant risk of thromboembolism and stent thrombosis must be weighed against the risk of major bleeding. This article reviews the current state of evidence to provide a framework for the practicing clinician.
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Affiliation(s)
| | | | | | - Barry F Uretsky
- University of Arkansas for Medical Sciences (UAMS) & Central Arkansas VA Medical Center, Little Rock, AR
| | - Abdul Hakeem
- University of Arkansas for Medical Sciences (UAMS) & Central Arkansas VA Medical Center, Little Rock, AR.
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Goto K, Nakai K, Shizuta S, Morimoto T, Shiomi H, Natsuaki M, Yahata M, Ota C, Ono K, Makiyama T, Nakagawa Y, Furukawa Y, Kadota K, Takatsu Y, Tamura T, Takizawa A, Inada T, Doi O, Nohara R, Matsuda M, Takeda T, Kato M, Shirotani M, Eizawa H, Ishii K, Lee JD, Takahashi M, Horie M, Takahashi M, Miki S, Aoyama T, Suwa S, Hamasaki S, Ogawa H, Mitsudo K, Nobuyoshi M, Kita T, Kimura T. Anticoagulant and antiplatelet therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Am J Cardiol 2014; 114:70-8. [PMID: 24925801 DOI: 10.1016/j.amjcard.2014.03.060] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/28/2014] [Accepted: 03/28/2014] [Indexed: 11/17/2022]
Abstract
The prevalence, intensity, safety, and efficacy of oral anticoagulation (OAC) in addition to dual antiplatelet therapy (DAPT) in "real-world" patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not yet been fully evaluated. In the Coronary REvascularization Demonstrating Outcome Study in Kyoto registry cohort-2, a total of 1,057 patients with AF (8.3%) were identified among 12,716 patients undergoing first PCI. Cumulative 5-year incidence of stroke was higher in patients with AF than in no-AF patients (12.8% vs 5.8%, p <0.0001). Although most patients with AF had CHADS2 score ≥2 (75.2%), only 506 patients (47.9%) received OAC with warfarin at hospital discharge. Cumulative 5-year incidence of stroke in the OAC group was not different from that in the no-OAC group (13.8% vs 11.8%, p = 0.49). Time in therapeutic range (TTR) was only 52.6% with an international normalized ratio of 1.6 to 2.6, and only 154 of 409 patients (37.7%) with international normalized ratio data had TTR ≥65%. Cumulative 5-year incidence of stroke in patients with TTR ≥65% was markedly lower than that in patients with TTR <65% (6.9% vs 15.1%, p = 0.01). In a 4-month landmark analysis in the OAC group, there was a trend for higher cumulative incidences of stroke and major bleeding in the on-DAPT (n = 286) than in the off-DAPT (n = 173) groups (15.1% vs 6.7%, p = 0.052 and 14.7% vs 8.7%, p = 0.10, respectively). In conclusion, OAC was underused and its intensity was mostly suboptimal in real-world patients with AF undergoing PCI, which lead to inadequate stroke prevention. Long-term DAPT in patients receiving OAC did not reduce stroke incidence.
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Affiliation(s)
- Koji Goto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kentaro Nakai
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takeshi Morimoto
- Division of General Medicine, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahiro Natsuaki
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mitsuhiko Yahata
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Chihiro Ota
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazushige Kadota
- Division of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshiki Takatsu
- Division of Cardiology, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan
| | - Takashi Tamura
- Division of Cardiology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Akinori Takizawa
- Division of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Tsukasa Inada
- Division of Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Osamu Doi
- Division of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Ryuji Nohara
- Division of Cardiology, Cardiovascular Center, the Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Mitsuo Matsuda
- Division of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Teruki Takeda
- Division of Cardiology, Koto Memorial Hospital, Higashioumi, Japan
| | - Masayuki Kato
- Division of Cardiology, Maizuru Kyosai Hospital, Maizuru, Japan
| | - Manabu Shirotani
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Nara, Japan
| | - Hiroshi Eizawa
- Division of Cardiology, Nishi-Kobe Medical Center, Kobe, Japan
| | - Katsuhisa Ishii
- Division of Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Jong-Dae Lee
- Division of Cardiology, University of Fukui Hospital, Fukui, Japan
| | | | - Minoru Horie
- Department of Cardiovascular and Respiratory, Shiga University of Medical Science, Otsu, Japan
| | | | - Shinji Miki
- Division of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Takeshi Aoyama
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Satoru Suwa
- Division of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka Japan
| | - Shuichi Hamasaki
- Department of Cardiovascular, Respiratory and Metabolic Medicine, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazuaki Mitsudo
- Division of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | | | - Toru Kita
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Puurunen M, Kiviniemi T, Nammas W, Schlitt A, Rubboli A, Nyman K, Karjalainen P, Kirchhof P, Lip GYH, Airaksinen JKE. Impact of anaemia on clinical outcome in patients with atrial fibrillation undergoing percutaneous coronary intervention: insights from the AFCAS registry. BMJ Open 2014; 4:e004700. [PMID: 24823675 PMCID: PMC4025460 DOI: 10.1136/bmjopen-2013-004700] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Anaemia has an adverse impact on the outcome in the general patient population undergoing percutaneous coronary intervention (PCI). The aim of this study was to analyse the impact of anaemia on the 12-month clinical outcome of patients with atrial fibrillation (AF) undergoing PCI and therefore requiring intense antithrombotic treatment. We hypothesised that anaemia might be associated with a worse outcome and more bleeding in these anticoagulated patients. SETTING Data were collected from 17 secondary care centres in Europe. PARTICIPANTS Consecutive patients with AF undergoing PCI were enrolled in the prospective, multicenter AFCAS (Atrial Fibrillation undergoing Coronary Artery Stenting) registry. Altogether, 929 patients participated in the study. Preprocedural haemoglobin concentration was available for 861 (92.7%; 30% women). The only exclusion criteria were inability or unwillingness to give informed consent. Anaemia was defined as a haemoglobin concentration of <12 g/dL for women and <13 g/dL for men. OUTCOME MEASURES The primary endpoint was occurrence of major adverse cardiac and cerebrovascular events (MACCE) or bleeding events. RESULTS 258/861 (30%) patients had anaemia. Anaemic patients were older, more often had diabetes, higher CHA2DS2-VASc scores, prior history of heart failure, chronic renal impairment and acute coronary syndrome. Anaemic patients had more MACCE than non-anaemic (29.1% vs 19.4%, respectively, p=0.002), and minor bleeding events (7.0% vs 3.3%, respectively, p=0.028), with a trend towards more total bleeding events (25.2% vs 21.7%, respectively, p=0.059). No difference was observed in antithrombotic regimens at discharge. In multivariate analysis, anaemia was an independent predictor of all-cause mortality at 12-month follow-up (hazard ratio 1.62, 95% CI 1.05 to 2.51, p=0.029). CONCLUSIONS Anaemia was a frequent finding in patients with AF referred for PCI. Anaemic patients had a higher all-cause mortality, more thrombotic events and minor bleeding events. Anaemia seems to be an identification of patients at risk for cardiovascular events and death. TRIAL REGISTRATION ClinicalTrials.gov number NCT00596570.
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Affiliation(s)
- Marja Puurunen
- Hemostasis Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Wail Nammas
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Axel Schlitt
- Medical Faculty, Martin Luther University Halle-Wittenberg, Halle-Wittenberg, Germany
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy
| | - Kai Nyman
- Department of Cardiology, Central Finland Central Hospital, Jyväskylä, Finland
| | | | - Paulus Kirchhof
- Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Gregory Y H Lip
- Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
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Ice DS, Shapiro TA, Gnall EM, Kowey PR. Unanswered questions in patients with concurrent atrial fibrillation and acute coronary syndrome. Am J Cardiol 2014; 113:888-96. [PMID: 24528617 DOI: 10.1016/j.amjcard.2013.11.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 11/14/2013] [Accepted: 11/14/2013] [Indexed: 11/19/2022]
Abstract
The best regimen for the long-term management of patients with atrial fibrillation who present with an acute coronary syndrome or require placement of a coronary stent remains unclear. Clinicians need to understand the risk of stroke, stent thrombosis, and major bleeding associated with treating these patients. Numerous studies and risk assessment schemes provide clinicians with an estimation of the risk of stroke, stent thrombosis, and major bleeding that may be associated with the use or avoidance of dual antiplatelet therapy with concurrent anticoagulation therapy (triple therapy). This review discusses the special antithrombotic needs in patients who have atrial fibrillation and either acute coronary syndrome or a requirement for percutaneous coronary intervention, including the published evidence for non-vitamin K oral anticoagulants, and the unanswered questions in this patient population. In conclusion, until the results of additional ongoing or planned randomized trials are known, clinicians must continue to rely on expert opinion and their own clinical judgment when treating these patients.
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Affiliation(s)
- Daniel S Ice
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania.
| | - Timothy A Shapiro
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
| | - Eric M Gnall
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
| | - Peter R Kowey
- Division of Cardiovascular Diseases, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, Jefferson Medical College, Philadelphia, Pennsylvania
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Albaladejo P. Gestion péri-opératoire des anticoagulants : vers de nouvelles recommandations ? ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2014. [DOI: 10.1016/s1878-6480(14)71484-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Czerwińska-Jelonkiewicz K, Witkowski A, Dąbrowski M, Banaszewski M, Księżycka-Majczyńska E, Chmielak Z, Kuśmierski K, Hryniewiecki T, Demkow M, Orłowska-Baranowska E, Stępińska J. Antithrombotic therapy - predictor of early and long-term bleeding complications after transcatheter aortic valve implantation. Arch Med Sci 2013; 9:1062-70. [PMID: 24482651 PMCID: PMC3902724 DOI: 10.5114/aoms.2013.39794] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 07/30/2013] [Accepted: 08/14/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) - aspirin and clopidogrel - is recommended after transcatheter aortic valve implantation (TAVI) without an evidence base. The main aim of the study was to estimate the impact of antithrombotic therapy on early and late bleeding. Moreover, we assessed the impact of patients' characteristics on early bleeding and the influence of bleeding on prognosis. MATERIAL AND METHODS Between 2009 and 2011, 83 consecutive TAVI patients, age 81.1 ±7.2 years, were included. Bleeding complications were defined by the Valve Academic Research Consortium (VARC) scale. The median follow-up was 12 ±15.5 months (range: 1 to 23) and included 68 (81.9%) patients. RESULTS Early bleeding occurred in 51 (61.4%) patients. Vitamin K antagonists (VKA) pre-TAVI (p = 0.001) and VKA + clopidogrel early post-TAVI (p = 0.04) were the safest therapies; in comparison to the safest one, peri-procedural DAPT (p = 0.002; p = 0.05) or triple anticoagulant therapy (TAT) (p = 0.003, p = 0.05) increased the risk for early bleeding. Predictors for early bleeding were: clopidogrel pre-TAVI (OR: 4.43, 95% CI: 1.02-19.24, p = 0.04), preceding percutaneous coronary intervention (PCI) (10.08, OR: 95% CI: 1.12-90.56, p = 0.04), anemia (OR: 4.00, 95% CI: 1.32-12.15, p = 0.01), age > 85 years (OR: 5.96, 95% CI: 1.47-24.13, p = 0.01), body mass index (BMI) (OR: 0.86, 95% CI: 0.74-0.99, p = 0.04). Late bleeding occurred in 35 patients (51.4%) on combined therapy, and none on VKA or clopidogrel monotherapy (p = 0.04). Bleeding complications did not worsen the survival. CONCLUSIONS This study seems to suggest that advanced age, BMI, and a history of anemia increased the risk for early bleeding after TAVI. Clopidogrel pre-TAVI should be avoided; therefore, time of preceding PCI should take into account discontinuation of clopidogrel in the pre-TAVI period. Vitamin K antagonists with clopidogrel seems to be the safest therapy in the early post-TAVI period, similarly as VKA/clopidogrel monotherapy in long-term prophylaxis.
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Affiliation(s)
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Maciej Dąbrowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Marek Banaszewski
- Department of Intensive Cardiac Care, Institute of Cardiology, Warsaw, Poland
| | | | - Zbigniew Chmielak
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Krzysztof Kuśmierski
- Department of Cardiac Surgery and Transplantology, Institute of Cardiology, Warsaw, Poland
| | - Tomasz Hryniewiecki
- Department of Acquired Valvular Disease, Institute of Cardiology, Warsaw, Poland
| | - Marcin Demkow
- Department of Coronary Artery Disease and Structural Heart Disease, Institute of Cardiology, Warsaw, Poland
| | | | - Janina Stępińska
- Department of Intensive Cardiac Care, Institute of Cardiology, Warsaw, Poland
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Sambola A, Montoro JB, Del Blanco BG, Llavero N, Barrabés JA, Alfonso F, Bueno H, Cequier A, Serra A, Zueco J, Sabaté M, Rodríguez-Leor O, García-Dorado D. Dual antiplatelet therapy versus oral anticoagulation plus dual antiplatelet therapy in patients with atrial fibrillation and low-to-moderate thromboembolic risk undergoing coronary stenting: design of the MUSICA-2 randomized trial. Am Heart J 2013; 166:669-75. [PMID: 24093846 DOI: 10.1016/j.ahj.2013.07.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 07/16/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Oral anticoagulation (OAC) is the recommended therapy for patients with atrial fibrillation (AF) because it reduces the risk of stroke and other thromboembolic events. Dual antiplatelet therapy (DAPT) is required after percutaneous coronary intervention and stenting (PCI-S). In patients with AF requiring PCI-S, the association of DAPT and OAC carries an increased risk of bleeding, whereas OAC therapy or DAPT alone may not protect against the risk of developing new ischemic or thromboembolic events. OBJECTIVE The MUSICA-2 study will test the hypothesis that DAPT compared with triple therapy (TT) in patients with nonvalvular AF at low-to-moderate risk of stroke (CHADS2 score ≤2) after PCI-S reduces the risk of bleeding and is not inferior to TT for preventing thromboembolic complications. DESIGN The MUSICA-2 is a multicenter, open-label randomized trial that will compare TT with DAPT in patients with AF and CHADS2 score ≤2 undergoing PCI-S. The primary end point is the incidence of stroke or any systemic embolism or major adverse cardiac events: death, myocardial infarction, stent thrombosis, or target vessel revascularization at 1 year of PCI-S. The secondary end point is the combination of any cardiovascular event with major or minor bleeding at 1 year of PCI-S. The calculated sample size is 304 patients. CONCLUSIONS The MUSICA-2 will attempt to determine the most effective and safe treatment in patients with nonvalvular AF and CHADS2 score ≤2 after PCI-S. Restricting TT for AF patients at high risk for stroke may reduce the incidence of bleeding without increasing the risk of thromboembolic complications.
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Affiliation(s)
- Antonia Sambola
- Cardiology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Balancing between bleeding and thromboembolism after percutaneous coronary intervention in patients with atrial fibrillation. Could triple anticoagulant therapy be a solution? ADVANCES IN INTERVENTIONAL CARDIOLOGY 2013; 9:234-40. [PMID: 24570724 PMCID: PMC3915991 DOI: 10.5114/pwki.2013.37501] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 06/22/2013] [Accepted: 06/28/2013] [Indexed: 01/18/2023] Open
Abstract
Introduction Atrial fibrillation (AF) has nowadays become a common disease as it comes along with medical procedures propagation in the ageing population with coexistent diseases. Hence a need for use of combined anticoagulant and antithrombotic therapy has arisen. According to the 2010 ESC guidelines on myocardial revascularization, short-term triple antithrombotic therapy after percutaneous coronary intervention (PCI) should be given if compelling indications exist. Aim To assess bleeding and thromboembolic events depending on the antithrombotic regimen in short- and long-term follow-up in patients with AF after PCI with stent implantation. Material and methods A 12-month prospective, non-randomized registry was conducted in the 3rd Department of Cardiology in the Upper Silesian Medical Center in Katowice from October 2008 to April 2011. One hundred and four patients in two groups – on triple therapy (TT; aspirin + clopidogrel + vitamin K antagonists (VKA; warfarin or acenocoumarol) n = 44) and on dual therapy (DT; aspirin + clopidogrel; n = 60) – were assessed 30 days and 12 months after angioplasty. Results All bleeding events occurred more often in the triple anticoagulated group in 30 days (TT 20.5% vs. DT 6.7%; p = 0.03) and after 12 months (TT 38.9% vs. DT 17.2%, p = 0.09). The difference in major bleeding events was not significant after 30 days (TT 9.1% vs. DT 3.3%; p = NS) or 12 months (TT 11.1% vs. DT 6.9%; p = NS). Thromboembolic events after 30 days (DT 5.0% vs. TT 2.3%) and 12 months (TT 11.1% vs. DT 3.4%) were comparable. The percentage of deaths after 30 days (DT 1.7% vs. TT 0.0%, p = NS) increased after 12 months (DT 13.8% vs. TT 0.0%, p = 0.09). Conclusions Significantly higher risk of bleeding on TT becomes blurred by a tendency to increased mortality in patients on DT.
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Suh SY, Kang WC, Oh PC, Choi H, Moon CI, Lee K, Han SH, Ahn T, Choi IS, Shin EK. Efficacy and safety of aspirin, clopidogrel, and warfarin after coronary artery stenting in Korean patients with atrial fibrillation. Heart Vessels 2013; 29:578-83. [PMID: 23974943 DOI: 10.1007/s00380-013-0399-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 08/02/2013] [Indexed: 11/25/2022]
Abstract
There are limited data on the optimal antithrombotic therapy for patients with atrial fibrillation (AF) who undergoing coronary stenting. We reviewed 203 patients (62.6 % men, mean age 68.3 ± 10.1 years) between 2003 and 2012, and recorded clinical and demographic characteristics of the patients. Clinical follow-up included major adverse cardiac and cerebrovascular events (MACCE) (cardiac death, myocardial infarction, target lesion revascularization, and stroke), stent thrombosis, and bleeding. The most commonly associated comorbidities were hypertension (70.4 %), diabetes mellitus (35.5 %), and congestive heart failure (26.6 %). Sixty-three percent of patients had stroke risk higher than CHADS2 score 2. At discharge, dual-antiplatelet therapy (aspirin, clopidogrel) was used in 166 patients (81.8 %; Group I), whereas 37 patients (18.2 %) were discharged with triple therapy (aspirin, clopidogrel, warfarin; Group II). The mean follow-up period was 42.0 ± 29.0 months. The mean international normalized ratio (INR) in group II was 1.83 ± 0.41. The total MACCE was 16.3 %, with stroke in 3.4 %. Compared with the group II, the incidence of MACCE (2.7 % vs 19.3 %, P = 0.012) and cardiac death (0 % vs 11.4 %, P = 0.028) were higher in the group I. Major and any bleeding, however, did not differ between the two groups. In multivariate analysis, no warfarin therapy (odds ratio 7.8, 95 % confidence interval 1.02-59.35; P = 0.048) was an independent predictor of MACCE. By Kaplan-Meier survival analysis, warfarin therapy was associated with a lower risk of MACCE (P = 0.024). In patients with AF undergoing coronary artery stenting, MACCE were reduced by warfarin therapy without increased bleeding, which might be related to tighter control with a lower INR value.
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Affiliation(s)
- Soon Yong Suh
- Cardiology Division, Department of Internal Medicine, Gil Medical Center, Gachon University, 1198 Guwol-dong, Namdong-gu, Incheon, 405-760, Korea
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