Dual Antiplatelet Therapy and Outcomes in Patients With Atrial Fibrillation and Acute Coronary Syndromes Managed Medically Without Revascularization: Insights From the TRILOGY ACS Trial.

Abstract

Associations between atrial fibrillation (AF), outcomes, and response to antiplatelet therapies in patients with acute coronary syndrome (ACS) managed medically without revascularization remain uncertain. We examined these associations for medically managed ACS patients randomized to dual antiplatelet therapy (DAPT) using patient data from the TRILOGY ACS trial. DAPT included aspirin plus clopidogrel 75 mg/d or prasugrel 10 mg/d (5 mg/d for those <60 kg or age ≥75 years). Patients receiving oral anticoagulants were excluded. Cox proportional hazards regression modeling was used to characterize associations between patients with AF (AF+) vs those without (AF-) and risk of ischemic and bleeding events, and to explore effects of randomized treatment on outcomes. Among 9101 patients with baseline AF status, 710 (7.8%) had AF. AF+ patients were older and had more comorbidities. Unadjusted associations of the composite of cardiovascular death/myocardial infarction/stroke were significantly higher among AF patients at 30 months (31.1% vs 18.4%; HR: 1.61, 95% CI: 1.35-1.92, P < 0.001), but differences did not persist after adjustment (HR: 1.16, 95% CI: 0.97-1.39, P = 0.11). When individual components of the composite endpoint were evaluated, 30-month risk of events in AF+ patients was significantly higher. Thirty-month risk of all-cause death was significantly higher in AF+ patients: 18.1% vs 11.1% (HR: 1.62, 95% CI: 1.30-2.02, P < 0.001). There was no significant interaction with randomized treatment and AF for the primary endpoint. Among medically managed high-risk ACS patients receiving DAPT, AF was associated with higher unadjusted risks of ischemic and bleeding outcomes that were similar by treatment group.

• Authors: Larry R Jackson 2nd, Jonathan P Piccini, Derek D Cyr, Matthew T Roe, Megan L Neely, Felipe Martinez, Thomas F Lüscher, Renato D Lopes, Kenneth J Winters, Harvey D White, Paul W Armstrong, Keith A A Fox, Dorairaj Prabhakaran, Deepak L Bhatt, E Magnus Ohman, Ramón Corbalán
• Journal: Clinical cardiology (Clin Cardiol) Vol. 39 Issue 9 Pg. 497-506 (Sep 2016) ISSN: 1932-8737 [Electronic] United States
• PMID: 27468086 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial)
• Copyright: © 2016 Wiley Periodicals, Inc.

Chemical References

• Platelet Aggregation Inhibitors
• Clopidogrel
• Prasugrel Hydrochloride
• Ticlopidine
• Aspirin

Topics

• Acute Coronary Syndrome (complications, diagnosis, drug therapy, mortality)
• Aged
• Aspirin (adverse effects, therapeutic use)
• Atrial Fibrillation (complications, diagnosis, mortality, therapy)
• Chi-Square Distribution
• Clopidogrel
• Double-Blind Method
• Drug Therapy, Combination
• Female
• Hemorrhage (chemically induced)
• Humans
• Kaplan-Meier Estimate
• Linear Models
• Male
• Middle Aged
• Multivariate Analysis
• Myocardial Infarction (etiology)
• Platelet Aggregation (drug effects)
• Platelet Aggregation Inhibitors (adverse effects, therapeutic use)
• Platelet Function Tests
• Prasugrel Hydrochloride (adverse effects, therapeutic use)
• Proportional Hazards Models
• Prospective Studies
• Risk Assessment
• Risk Factors
• Stroke (etiology)
• Ticlopidine (adverse effects, analogs & derivatives, therapeutic use)
• Time Factors
• Treatment Outcome