Combining Oral Anticoagulants With Platelet Inhibitors in Patients With Atrial Fibrillation and Coronary Disease.

Abstract

BACKGROUND:

The optimal treatment strategy when combining antiplatelets with oral anticoagulants in patients with atrial fibrillation (AF) and myocardial infarction (MI) or undergoing percutaneous coronary intervention (PCI) is unknown.

OBJECTIVES:

The authors investigated the risk of bleeding, ischemic stroke, MI, and all-cause mortality associated with direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in combination with aspirin, clopidogrel, or both in patients with AF following MI and/or PCI.

METHODS:

Danish nationwide registries were used to identify patients with AF who were admitted with a MI and/or underwent PCI, between August 2011 and June 2017, treated with OAC in combination with antiplatelet(s). Patients were followed for 12 months or until an outcome, study end, or death. Standardized absolute risks were estimated on the basis of outcome-specific Cox regression models adjusted for potential confounders. Average treatment effects were obtained as standardized absolute risk differences (ARD) in risks at 3 and 12 months using the g-formula.

RESULTS:

Overall, 3,222 patients were included in the study population, of which 875 (27%) were treated with VKA+single antiplatelet therapy (SAPT), 595 (18%) were treated with DOAC+SAPT, 1,074 (33%) were treated with VKA+dual antiplatelet therapy (DAPT), and 678 (22%) were treated with DOAC+DAPT. At 3 months, there was a significant difference in the absolute risk of MI associated with DOAC+SAPT compared with VKA+SAPT (3-month ARD -1.53% (95% confidence interval: -3.08% to -0.11%), with no significant differences found regarding bleeding, ischemic stroke, and all-cause mortality. Compared with VKA+DAPT, DOAC+DAPT was associated with a significantly reduced risk of bleeding (3-month ARD -1.96%, 95% confidence interval: -3.46% to -0.88%), with no significant difference in the absolute risk of all-cause mortality, stroke, or MI.

CONCLUSIONS:

In a real-world population of AF patients with MI and/or after PCI, the authors found that DOAC in combination with DAPT was associated with a significantly decreased risk of bleeding and similar thromboembolic protection compared with VKA in combination with DAPT.

• Authors: Caroline Sindet-Pedersen, Morten Lamberts, Laila Staerk, Anders Nissen Bonde, Jeffrey S Berger, Jannik Langtved Pallisgaard, Morten Lock Hansen, Christian Torp-Pedersen, Gunnar H Gislason, Jonas Bjerring Olesen
• Journal: Journal of the American College of Cardiology (J Am Coll Cardiol) Vol. 72 Issue 15 Pg. 1790-1800 (10 09 2018) ISSN: 1558-3597 [Electronic] United States
• PMID: 30286922 (Publication Type: Journal Article, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Chemical References

• Anticoagulants
• Antithrombins
• Platelet Aggregation Inhibitors
• Warfarin
• Clopidogrel
• Aspirin

Topics

• Aged
• Anticoagulants (administration & dosage, adverse effects)
• Antithrombins (administration & dosage, adverse effects)
• Aspirin (administration & dosage, adverse effects)
• Atrial Fibrillation (drug therapy, epidemiology)
• Clopidogrel (administration & dosage, adverse effects)
• Comorbidity
• Coronary Artery Disease (epidemiology, therapy)
• Denmark (epidemiology)
• Drug Therapy, Combination (methods)
• Female
• Hemorrhage (diagnosis, etiology)
• Humans
• Male
• Middle Aged
• Myocardial Infarction (epidemiology, surgery)
• Outcome and Process Assessment, Health Care
• Percutaneous Coronary Intervention (adverse effects, methods)
• Platelet Aggregation Inhibitors (administration & dosage, adverse effects)
• Registries
• Risk Assessment
• Stroke (diagnosis, etiology)
• Warfarin (administration & dosage, adverse effects)