Effect of Procedure and Coronary Lesion Characteristics on Clinical Outcomes Among Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: Insights From the PIONEER AF-PCI Trial.

Abstract

OBJECTIVES:

This study sought to assess whether there were significant interactions of procedural access strategies and lesion characteristics with bleeding and ischemic events among atrial fibrillation (AF) patients anticoagulated with rivaroxaban or warfarin following a percutaneous coronary intervention.

BACKGROUND:

Among stented AF patients, the impact of procedural access strategies or lesion characteristics on antithrombotic safety and efficacy outcomes is unclear.

METHODS:

In the PIONEER AF-PCI (An Open-label, Randomized, Controlled, Multicenter Study Exploring Two Treatment Strategies of Rivaroxaban and a Dose-Adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects With Atrial Fibrillation Who Undergo Percutaneous Coronary Intervention) trial, 2,124 patients were randomized to 3 groups and followed for 12 months: 1) rivaroxaban 15 mg once daily plus a P2Y12 inhibitor (n = 709); 2) rivaroxaban 2.5 mg twice a day plus dual antiplatelet therapy (DAPT) (n = 709); and 3) dose-adjusted warfarin plus DAPT (n = 706). Kaplan-Meier rates of clinically significant bleeding and major adverse cardiovascular events were compared between treatments stratified by subgroups of procedure type and lesion characteristics.

RESULTS:

Compared with warfarin, both rivaroxaban regimens consistently reduced clinically significant bleeding across subgroups of radial versus femoral arterial access and by vascular closure device use. Treatment effect of rivaroxaban on major adverse cardiovascular events did not vary when stratified by ischemia-driven revascularization, urgency of revascularization, location of culprit artery, presence of bifurcation lesion, presence of thrombus, type, and length of stent or number of stents (interaction p > 0.05 for all subgroups).

CONCLUSIONS:

Among stented AF patients requiring long-term oral anticoagulation, there was no effect modification by procedure or lesion characteristics of either clinically significant bleeding or major adverse cardiovascular events. Rivaroxaban-based therapy was superior to warfarin plus DAPT in bleeding outcomes regardless of the type of stent or arterial access during the index coronary revascularization. (A Study Exploring Two Strategies of Rivaroxaban [JNJ39039039; BAY-59-7939] and One of Oral Vitamin K Antagonist in Patients With Atrial Fibrillation Who Undergo Percutaneous Coronary Intervention [PIONEER AF-PCI]; NCT01830543).

• Authors: Mathieu Kerneis, C Michael Gibson, Gerald Chi, Roxana Mehran, Fahad AlKhalfan, Usama Talib, Seyedmahdi Pahlavani, Mahshid Mir, Christoph Bode, Jonathan L Halperin, Tarek Nafee, Eric D Peterson, Freek W A Verheugt, Peter Wildgoose, Martin van Eickels, Gregory Y H Lip, Keith A A Fox, Marc Cohen
• Journal: JACC. Cardiovascular interventions (JACC Cardiovasc Interv) Vol. 11 Issue 7 Pg. 626-634 (04 09 2018) ISSN: 1876-7605 [Electronic] United States
• PMID: 29550085 (Publication Type: Comparative Study, Journal Article, Multicenter Study, Randomized Controlled Trial, 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
• Factor Xa Inhibitors
• Platelet Aggregation Inhibitors
• Warfarin
• Rivaroxaban

Topics

• Administration, Oral
• Aged
• Anticoagulants (administration & dosage, adverse effects)
• Atrial Fibrillation (complications, diagnosis, drug therapy, mortality)
• Coronary Artery Disease (complications, diagnostic imaging, mortality, surgery)
• Drug Administration Schedule
• Factor Xa Inhibitors (administration & dosage, adverse effects)
• Female
• Hemorrhage (chemically induced)
• Humans
• Male
• Myocardial Infarction (etiology, mortality)
• Percutaneous Coronary Intervention (adverse effects, instrumentation, mortality)
• Platelet Aggregation Inhibitors (administration & dosage, adverse effects)
• Risk Factors
• Rivaroxaban (administration & dosage, adverse effects)
• Stents
• Stroke (etiology, mortality)
• Time Factors
• Treatment Outcome
• Warfarin (administration & dosage, adverse effects)