scholarly journals Novel Dual Therapy: A Paradigm Shift in Anticoagulation in Patients of Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

TH Open ◽  
2020 ◽  
Vol 04 (04) ◽  
pp. e332-e343
Author(s):  
Akshyaya Pradhan ◽  
Monika Bhandari ◽  
Pravesh Vishwakarma ◽  
Rishi Sethi
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Triple Therapy ◽  
Antiplatelet Therapy ◽  
Paradigm Shift ◽  
Oral Anticoagulants ◽  
Dual Therapy ◽  
Coronary Intervention ◽  
Bleeding Events ◽  
Percutaneous Coronary

AbstractPatients with atrial fibrillation (AF) on long-term oral anticoagulation (OAC) either have underlying coronary artery disease or suffer from acute coronary syndromes necessitating a percutaneous coronary intervention (PCI). In such a scenario, an amalgamation of antiplatelet and antithrombotic therapy (conventionally called as “triple therapy”) is obligatory for preventing coronary ischemia and stroke. But such ischemic benefits are accrued at the cost of increased bleeding. We also now know that bleeding events following PCI are related to increased mortality. Balancing the bleeding and ischemic risks is often a clinical dilemma. With the advent of novel oral anticoagulants (NOAC's) with preserved efficacy and attenuated bleeding rates, anticoagulation in AF is undergoing paradigm shift. The spotlight is now shifting from conventional triple therapy (vitamin-K antagonist + dual antiplatelet therapy [VKA + DAPT]) to novel dual therapy (NOAC + single antiplatelet therapy [SAPT]) in situation of anticoagulated AF patients undergoing PCI. Such a strategy aims to ameliorate the higher bleeding risk with conventional VKA's while retaining the ischemic benefits. In this review, we briefly discuss the need for combination therapy, trials of novel dual therapy, strategies for mitigating bleeding, the current guidelines, and the future perspectives in AF undergoing PCI with stent(s).

scholarly journals Antithrombotic Therapy With Ticagrelor in Atrial Fibrillation Subjects After Percutaneous Coronary Intervention

2021 ◽  
Vol 8 ◽  
Author(s):  
Wenbin Lu ◽  
Yu Wang ◽  
Lijuan Chen ◽  
Yongjun Li ◽  
Rui Zhang ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Cardiovascular Events ◽  
Therapy Group ◽  
Dual Therapy ◽  
Coronary Intervention ◽  
Hazard Ratio ◽  
Bleeding Events ◽  
Percutaneous Coronary

Background: Warfarin, along with aspirin and clopidogrel, has long been recommended for patients with atrial fibrillation (AF) who are undergoing percutaneous coronary intervention with a drug-eluting stent (PCI-DES). However, this triple therapy has been known to increase the risk of bleeding complications. Meanwhile, there is no evidence from prospective trials on the use of ticagrelor in a dual therapy. We here aimed to compare the antiplatelet drug ticagrelor as a dual antithrombotic agent to aspirin and clopidogrel in bleeding events.Methods: In this multicenter, active-controlled, open-label, randomized trial, patients with AF taking warfarin who had undergone PCI-DES were randomly assigned to the ticagrelor therapy group (Dual group) or the clopidogrel plus aspirin therapy group (Triple group). The primary and secondary endpoints were overall bleeding events and major bleeding events, respectively, according to the Thrombolysis in Myocardial Infarction (TIMI) criteria at 6 months. Cardiovascular events [re-PCI, surgical bypass, myocardial infarction (MI), heart failure, rehospitalization due to angina pectoris, stent thrombosis and death due to cardiovascular causes] at 6 months were also recorded.Results: A total of 296 patients from 12 medical centers in China were randomized after PCI-DES to either the Dual therapy group (n = 148) or the Triple group (n = 146) for 6 months. The overall incidence of bleeding events at 6 months was 36.49% in the Dual therapy group and 35.62% in the Triple group [hazard ratio, 0.930; 95% confidence interval (CI), 0.635 to 1.361; P = 0.7088]. The incidence of the secondary endpoint over 6 months was 4.73% in the Dual therapy group and 1.37% in the Triple group (hazard ratio, 0.273; 95% CI, 0.057 to 1.315; P = 0.1056). Cardiovascular event occurrence was also comparable in both groups at 6 months (18.24 vs. 16.44%; hazard ratio, 0.845; 95% CI, 0.488 to 1.465; P = 0.5484).Conclusions: The incidence of total bleeding events in AF patients treated with ticagrelor was comparable to that in patients treated with clopidogrel plus aspirin at 6 month; Meanwhile, the incidence of cardiovascular events were also comparable between the groups.Clinical Trial Registration: MANJUSRI, ClinicalTrials.gov# NCT02206815, 2014, August 1st

Thrombin Generation in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Cardiology ◽  
2021 ◽  
pp. 1-6
Author(s):  
Chen Gurevitz ◽  
Alon Eisen ◽  
Eli Lev ◽  
Osnat Itzhaki Ben Zadok ◽  
Leor Perl ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Triple Therapy ◽  
Thrombin Generation ◽  
Dual Therapy ◽  
Coronary Intervention ◽  
Withdrawal Time ◽  
Coronary Syndrome ◽  
Percutaneous Coronary ◽  
Significant Difference

<b><i>Background:</i></b> The optimal antithrombotic treatment for patients with atrial fibrillation (AF) that undergo percutaneous coronary intervention (PCI) is controversial. Dual therapy (clopidogrel and a direct oral anticoagulant [DOAC]) is safer than triple therapy (warfarin, aspirin, and clopidogrel), while efficacy is unclear. We aimed to evaluate thrombin generation (TG) under dual and triple therapy. <b><i>Methods:</i></b> A noninterventional prospective trial in patients with AF undergoing PCI. Patients received 4 weeks of triple therapy with aspirin, clopidogrel, and a DOAC followed by aspirin withdrawal. TG was measured in platelet-rich plasma (PRP) and platelet-poor plasma (PPP) at 3 <i>five to 21</i> points, day 1 after PCI (TIME 0), 4 weeks after PCI (TIME 1), and 2 weeks after aspirin withdrawal (TIME 2). <b><i>Results:</i></b> Twenty-three patients (18 men, median age 78 years, 83% with acute coronary syndrome) were included. Endogenous thrombin potential (ETP) in PPP was high at TIME 0 compared with TIME 1 (ETP 3,178 ± 248 nM vs. 2,378 ± 222 nM, <i>p</i> = 0.005). These results remained consistent when measured in PRP. No significant difference in ETP was found before (TIME 1) and after aspirin withdrawal (TIME 2) although few patients had high ETP levels after stopping aspirin. <b><i>Conclusions:</i></b> TG potential is high immediately after PCI and decreases 4 weeks after PCI in patients receiving triple therapy. TG remains constant after aspirin withdrawal in most patients, suggesting that after 1 month the antithrombotic effect of dual therapy may be similar to triple therapy.

scholarly journals Clinical Utility of the BIWACO Score for Patients With Atrial Fibrillation After Percutaneous Coronary Intervention

2021 ◽  
Author(s):  
Teruki Takeda ◽  
Tomohiro Dohke ◽  
Yoshiki Ueno ◽  
Toshiki Mastui ◽  
Masanori Fujii ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Area Under The Curve ◽  
Dual Therapy ◽  
Coronary Intervention ◽  
Current Status ◽  
Risk Scores ◽  
Bleeding Events ◽  
Percutaneous Coronary ◽  
Multicenter Survey

Abstract Background: No predictive clinical risk scores for net adverse clinical events (NACE) have been developed in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). Methods: We evaluated the NACE in order to develop clinically applicable risk-stratification scores in the BIWACO study, a multicenter survey which enrolled a total of 7837 patients. We also investigated the current status and time trends for the use of antithrombotic drugs.Results: A total of 188 AF patients who had received PCI were enrolled. At discharge, 65% of patients were prescribed a triple therapy (TT), 6% were prescribed a dual therapy, the remaining 29% of patients received dual-antiplatelet therapy. Over 3 years, the fraction of patients continuing TT decreased by 15%, whereas only 2% received oral anticoagulant alone. NACE developed in 20% of patients, resulting in the deaths of 5% patients, and 13% experiencing bleeding events. We developed risk scores for NACE comprising the five best predictive items, which we designated BIWACO scores. The area under the curve was 0.774 for NACE. Conclusions: Our study explored the differences in treatment practices and guideline recommendations for antithrombotic therapy. We concluded that our BIWACO score is useful for predicting clinical outcomes in AF-patients after PCI.

scholarly journals Atrial fibrillation patients undergoing percutaneous coronary intervention: dual or triple antithrombotic therapy with non-vitamin K antagonist oral anticoagulants

2020 ◽  
Vol 22 (Supplement_I) ◽  
pp. I22-I31
Author(s):  
Andreas Goette ◽  
Pascal Vranckx
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Triple Therapy ◽  
Vitamin K ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Coronary Intervention ◽  
Vitamin K Antagonist ◽  
Percutaneous Coronary ◽  
The Impact

Abstract About 20% of all atrial fibrillation (AF) patients develop coronary artery disease, which requires coronary stenting [percutaneous coronary intervention (PCI)]. Thus, this subcohort of AF patients may require aggressive antithrombotic therapy encompassing vitamin K antagonist (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) plus aspirin and a P2Y12 inhibitor. At present, four clinical Phase IIIb trials using dabigatran, rivaroxaban, apixaban, or edoxaban, were published. These studies assessed the impact of NOACs as a part of DAT therapy vs. triple therapy. Compared with triple therapy, NOAC-based DAT has been shown to be associated with reduced major bleeding as well as intracranial haemorrhages. The benefit, however, is somewhat counterbalanced by a higher risk of stent-related ischaemia during the early phase of dual therapy. Thus, triple therapy after stenting is appropriate for at least 14 days with a maximum of 30 days. Thereafter, DAT including a NOAC is the therapy of choice in AF PCI patients to reduce the risk of bleeding during a 1 year of follow-up compared to VKA-based regimes. The present review summarizes the published study results and demonstrates differences in trial design and reported outcomes.

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