Comparative Analysis of the Effects of Three Antithrombotic Regimens on Clinical Outcomes of Patients with Atrial Fibrillation and Recent Percutaneous Coronary Intervention with Stent. A Retrospective Cohort Study

Authors

  • Renato De Vecchis Cardiology Unit, Presidio Sanitario Intermedio “Elena d’Aosta”, ASL Napoli 1 Centro, Napoli, Italy
  • Cesare Baldi Heart Department, Interventional Cardiology, A.O.U. “San Giovanni di Dio e Ruggi D’Aragona”, Salerno, Italy
  • Francesco Piemonte Cardiology Division, “San Giovanni di Dio” Hospital, ASL Napoli 2 Nord, Frattamaggiore (NA), Italy

DOI:

https://doi.org/10.6000/1929-6029.2015.04.03.3

Keywords:

Atrial fibrillation, percutaneous coronary intervention, oral anticoagulant therapy, antithrombotic therapy, major adverse cardiovascular events, bleeding

Abstract

Introduction: Chronic atrial fibrillation (AF), coexisting with a history of recent coronary angioplasty with stent (PCI-S) represents an encoded indication for oral anticoagulation with warfarin (OAC) plus dual antiplatelet therapy (DAPT).

Methods: Using a retrospective cohort study we determined the respective impacts on cardio- vascular outcomes of three different pharmacologic regimens, i.e., triple therapy (TT) with warfarin + clopidogrel and aspirin, dual therapy (DT) with warfarin +clopidogrel or aspirin, dual antiplatelet therapy (DAPT) with clopidogrel + aspirin. Outcomes of interest were all-cause mortality, ischemic cardiac events, ischemic cerebral events, bleeding events. The inclusion criterion was the coexistence of an indication for OAC (e.g., chronic AF) with an indication for dual antiplatelet therapy due to recent PCI-S.

Results: Among the 98 patients enrolled, 48 (49%), 31 (31.6%), and 19(19.4%) patients were prescribed TT, DT, and DAPT, respectively. Throughout a mean follow-up of 378± 15.7days, there were no significant differences between the three regimens for all abovementioned outcomes. In particular, the total frequency of major bleeding was similar in the three groups: 5 cases (10.4%) in TT, one case (3.22%) in DT and no case in DAPT groups (p [chi-square test] = 0.1987).

Conclusions: TT, DT and DAPT displayed similar efficacy and safety. Although the superiority of OAC vs. DAPT for stroke prevention in AF patients has been demonstrated by previous randomized trials, a smaller frequency of high thromboembolic risks' features in DAPT group of the present study may have prevented the observation of a higher incidence of ischemic stroke in this group.

References

Connolly S, Pogue J, Hart R, Pfeffer M, Hohnloser S, Chrolavicius S, Pfeffer M, Hohnloser S, Yusuf S, for the for the ACTIVE Writing Group of the ACTIVE Investigators. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events (ACTIVEW): a randomised controlled trial. Lancet 2006; 367: 1903-12. http://dx.doi.org/10.1016/S0140-6736(06)68845-4 DOI: https://doi.org/10.1016/S0140-6736(06)68845-4

Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC). Eur Heart J 2012; 33: 2569-619. http://dx.doi.org/10.1093/eurheartj/ehs215 DOI: https://doi.org/10.1093/eurheartj/ehs215

Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345(7): 494-502. http://dx.doi.org/10.1056/NEJMoa010746 DOI: https://doi.org/10.1056/NEJMoa010746

Orford JL, Fasseas P, Melby S, Burger K, Steinhubl SR, Holmes DR, Berger PB. Safety and efficacy of aspirin, clopidogrel, and warfarin after coronary stent placement in patients with an indication for anticoagulation. Am Heart J 2004; 147(3): 463-7. http://dx.doi.org/10.1016/j.ahj.2003.06.004 DOI: https://doi.org/10.1016/j.ahj.2003.06.004

Rubboli A, Brancaleoni R, Colletta M, Herzfeld J, Sangiorgio P, Di Pasquale G. Contemporary antithrombotic treatment after coronary stenting in patients with indication for long-term anticoagulation. Minerva Cardioangiol 2006; 54(5): 687-93.

Hermosillo AJ, Spinler SA. Aspirin, clopidogrel, and warfarin: is the combination appropriate and effective or inappropriate and too dangerous? Ann Pharmacother 2008; 42(6): 790-805. http://dx.doi.org/10.1345/aph.1K591 DOI: https://doi.org/10.1345/aph.1K591

Rubboli A, Verheugt FW. Antithrombotic treatment for patients on oral anticoagulation undergoing coronary stenting: a review of the available evidence and practical suggestions for the clinician. Int J Cardiol 2008; 123(3): 234-9. http://dx.doi.org/10.1016/j.ijcard.2007.02.017 DOI: https://doi.org/10.1016/j.ijcard.2007.02.017

Lamberts M, Gislason GH, Olesen JB, Kristensen SL, Schjerning Olsen AM, Mikkelsen A, Christensen CB, Lip GY, Køber L, Torp-Pedersen C, Hansen ML. Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. J Am Coll Cardiol 2013; 62(11): 981-9. http://dx.doi.org/10.1016/j.jacc.2013.05.029 DOI: https://doi.org/10.1016/j.jacc.2013.05.029

Lamberts M, Olesen JB, Ruwald MH, Hansen CM, Karasoy D, Kristensen SL, Køber L, Torp-Pedersen C, Gislason GH, Hansen ML. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study. Circulation 2012; 126(10): 1185-93. http://dx.doi.org/10.1161/CIRCULATIONAHA.112.114967 DOI: https://doi.org/10.1161/CIRCULATIONAHA.112.114967

Rubboli A, Milandri M, Castelvetri C, Cosmi B. Meta-analysis of trials comparing oral anticoagulation and aspirin versus dual antiplatelet therapy after coronary stenting. Clues for the management of patients with an indication for long-term anticoagulation undergoing coronary stenting. Cardiology 2005; 104(2): 101-6. http://dx.doi.org/10.1159/000086918 DOI: https://doi.org/10.1159/000086918

Lane DA, Lip GY. Use of the CHA2DS2-VASc and HAS-BLED scores to aid decision making for thromboprophylaxis in nonvalvular atrial fibrillation. Circulation 2012; 126(7): 860-5. http://dx.doi.org/10.1161/CIRCULATIONAHA.111.060061 DOI: https://doi.org/10.1161/CIRCULATIONAHA.111.060061

Silber S, Hoffmeister HM, Bode C. [Optimal platelet inhibition after coronary stent implantation. Current status]. [Article in German] Herz 2008; 33(4): 244-53. http://dx.doi.org/10.1007/s00059-008-3138-9 DOI: https://doi.org/10.1007/s00059-008-3138-9

Park SJ, Kang SM, Park DW. Dual antiplatelet therapy after drug-eluting stents: defining the proper duration. Coron Artery Dis 2014; 25(1): 83-9. http://dx.doi.org/10.1097/MCA.0000000000000066 DOI: https://doi.org/10.1097/MCA.0000000000000066

Rubboli A, Schlitt A, Kiviniemi T, Biancari F, Karjalainen PP, Valencia J, Laine M, Kirchhof P, Niemelä M, Vikman S, Lip GY, Airaksinen KE, AFCAS Study Group. One-year outcome of patients with atrial fibrillation undergoing coronary artery stenting: an analysis of the AFCAS registry. Clin Cardiol 2014; 37(6): 357-64. http://dx.doi.org/10.1002/clc.22254 DOI: https://doi.org/10.1002/clc.22254

Dewilde WJ, Oirbans T, Verheugt FW, Kelder JC, De Smet BJ, Herrman JP, Adriaenssens T, Vrolix M, Heestermans AA, Vis MM, Tijsen JG, van 't Hof AW, tenBerg JM, WOEST study investigators. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381(9872): 1107-15. http://dx.doi.org/10.1016/S0140-6736(12)62177-1 DOI: https://doi.org/10.1016/S0140-6736(12)62177-1

Rubboli A, Saia F, Sciahbasi A, Bacchi-Reggiani ML, Steffanon L, Briguori C, Calabrò P, Palmieri C, Rizzi A, Imperadore F, Sangiorgi GM, Valgimigli M, Carosio G, Steffenino G, Galvani M, Di Pasquale G, La Vecchia L, Maggioni AP, Bolognese L, WARfarin and Coronary STENTing (WAR-STENT) Study Group. Outcome of patients on oral anticoagulation undergoing coronary artery stenting: data from discharge to 12months in the Warfarin and Coronary Stenting (WAR-STENT) Registry. J Invasive Cardiol 2014; 26(11): 563-9.

Lip GY, Huber K, Andreotti F, Arnesen H, Airaksinen KJ, Cuisset T, Kirchhof P, Marín F; European Society of Cardiology Working Group on Thrombosis. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/ stenting. Thromb Haemost 2010; 103(1): 13-28. http://dx.doi.org/10.1160/TH09-08-0580 DOI: https://doi.org/10.1160/TH09-08-0580

Faxon DP, Eikelboom JW, Berger PB, Holmes DR, Bhatt DL, Moliterno DJ, Becker RC, Angiolillo DJ. Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective. Thromb Haemost 2011; 106(4): 572-84. http://dx.doi.org/10.1160/TH11-04-0262 DOI: https://doi.org/10.1160/TH11-04-0262

Ahmad Y, Lip GY, Apostolakis S. New oral anticoagulants for stroke prevention in atrial fibrillation: impact of gender, heart failure, diabetes mellitus and paroxysmal atrial fibrillation. Expert Rev Cardiovasc Ther 2012; 10(12): 1471-80. http://dx.doi.org/10.1586/erc.12.148= DOI: https://doi.org/10.1586/erc.12.148

Downloads

Published

2015-08-18

How to Cite

De Vecchis, R., Baldi, C., & Piemonte, F. (2015). Comparative Analysis of the Effects of Three Antithrombotic Regimens on Clinical Outcomes of Patients with Atrial Fibrillation and Recent Percutaneous Coronary Intervention with Stent. A Retrospective Cohort Study. International Journal of Statistics in Medical Research, 4(3), 260–269. https://doi.org/10.6000/1929-6029.2015.04.03.3

Issue

Section

General Articles