Dual Antithrombotic Therapy in Atrial Fibrillation Patients undergoing Percutaneous Coronary Angioplasty: The Impact of Bleeding Risk Score on Outcome

Abstract Aims Patients with atrial fibrillation undergoing coronary intervention are at higher bleeding risk due to the concomitant need for oral anticoagulation and antiplatelet therapy. The RE-DUAL PCI trial demonstrated better safety with dual antithrombotic therapy (DAT: dabigatran 110 or 150 mg b.i.d., clopidogrel or ticagrelor) compared to triple antithrombotic therapy (TAT: warfarin, clopidogrel or ticagrelor, and aspirin). We explored the impact of baseline bleeding risk based on the PRECISE-DAPT score for decision-making regarding DAT vs. TAT. Methods and results A score ≥25 points qualified high bleeding risk (HBR). Comparisons were made for the primary safety endpoint International Society of Thrombosis and Haemostasis major or clinically relevant non-major bleeding, and the composite efficacy endpoint of death, thrombo-embolic events, or unplanned revascularization, analysed by time-to-event analysis. PRECISE-DAPT was available in 2336/2725 patients, and 37.9% were HBR. Compared to TAT, DAT with dabigatran 110 mg reduced bleeding risk both in non-HBR [hazard ratio (HR) 0.42, 95% confidence interval (CI) 0.31–0.57] and HBR (HR 0.70, 95% CI 0.52–0.94), with a greater magnitude of benefit among non-HBR (Pint = 0.02). Dual antithrombotic therapy with dabigatran 150 mg vs. TAT reduced bleeding in non-HBR (HR 0.60, 95% CI 0.45–0.80), with a trend toward less benefit in HBR patients (HR 0.92, 95% CI 0.63–1.34; Pint = 0.08). The risk of ischaemic events was similar on DAT with dabigatran (both 110 and 150 mg) vs. TAT in non-HBR and HBR patients (Pint = 0.45 and Pint = 0.56, respectively). Conclusions PRECISE-DAPT score appeared useful to identify AF patients undergoing PCI at further increased risk of bleeding complications and may help clinicians identifying the antithrombotic regimen intensity with the best benefit–risk ratio in an individual patient.

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THE IMPACT OF PERCUTANEOUS CORONARY ANGIOPLASTY TO PREDICT MORTALITY AND NEUROLOGICAL OUTCOME IN OUT-OF-HOSPITAL CARDIAC ARREST PATIENTS WITHOUT ST-SEGMENT ELEVATION

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(20)30651-3 ◽

2020 ◽

Vol 75 (11) ◽

pp. 24

Author(s):

Junji Mastuda ◽

Momiji Kaede ◽

Shun Nakamura ◽

Masahiko Nakao ◽

Takayuki Niida ◽

...

Keyword(s):

Cardiac Arrest ◽

Coronary Angioplasty ◽

Neurological Outcome ◽

Percutaneous Coronary Angioplasty ◽

St Segment Elevation ◽

St Segment ◽

Percutaneous Coronary ◽

The Impact ◽

Hospital Cardiac Arrest

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

European Heart Journal Supplements ◽

10.1093/eurheart/suaa101 ◽

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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Antithrombotic Strategies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Current Pharmaceutical Design ◽

10.2174/1381612824666171227215246 ◽

2018 ◽

Vol 24 (4) ◽

pp. 496-510

Author(s):

Daorong Pan ◽

Xiaomin Ren ◽

Zuoying Hu

Keyword(s):

Atrial Fibrillation ◽

Percutaneous Coronary Intervention ◽

Antithrombotic Therapy ◽

Clinical Decision Making ◽

Anticoagulation Therapy ◽

Bleeding Risk ◽

Coronary Intervention ◽

Clinical Decision ◽

Bleeding Complications ◽

Percutaneous Coronary

The optimal strategy of antithrombotic therapy for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention remains to be a question to be answered. The major challenge in such population is the balance between the benefit of reduced stroke and coronary ischemic events, against the risk of increased bleeding complications. Thus, both thrombotic and bleeding risk assessments should be included into clinical decision-making process for such patients. Currently, there is limited evidence based on randomized trials with adequate power to show the superiority of any strategy in the beneficial profile of safety and efficacy, thus limited recommendations are provided by clinical guidelines. Given the recent advancement in this field, our review provided an overview of the available risk stratification schemes for stroke and bleeding risk for AF patients, discussed the multiple questions in the optimal regimens of oral antiplatelet and anticoagulation therapy, and summarized evidence and recommendations related to long-term antithrombotic therapy for AF patients receiving stent implications.

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Could the PARIS Risk Scores Be Useful for the Choice of Triple vs Dual Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention?

Cardiology ◽

10.1159/000521673 ◽

2022 ◽

Author(s):

Leonardo De Luca ◽

Leonardo Bolognese ◽

Andrea Rubboli ◽

Donata Lucci ◽

Domenico Gabrielli ◽

...

Keyword(s):

Atrial Fibrillation ◽

Percutaneous Coronary Intervention ◽

Antithrombotic Therapy ◽

Bleeding Risk ◽

Daily Practice ◽

Coronary Intervention ◽

Risk Scores ◽

Thrombotic Risk ◽

Percutaneous Coronary ◽

Study Results

Introduction. Current guidelines recommend dual antithrombotic therapy (DAT) for the majority of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) and suggest a short course of triple antithrombotic therapy (TAT) for those at very high thrombotic risk (TR) but low bleeding risk (BR). Methods. We analyze if the PARIS ischemic-hemorrhagic scale could be useful for the choice of antithrombotic strategy in patients with acute coronary syndromes (ACS) and AF treated with coronary stenting enrolled in the prospective, observational, nationwide MATADOR-PCI study. Results. Among the 588 patients discharged alive, a TAT was prescribed in 381 (64.8%) and DAT in 52 (8.8%) patients. According to the PARIS scoring system, 142 (24.2%) were classified as low, 244 (41.5%) as intermediate and 292 (34.3%) as high TR. In parallel, 87 (14.8%) were categorized in the low, 260 (44.2%) in the intermediate and 241 (41.0%) in the high-risk stratum for major bleedings. Crossing the various strata of the two PARIS risk scores, the largest group of patients consisted of those at high TR and BR (n=130, 22%), followed by those at intermediate risk according to both scores (n=122, 21%). At discharge, TAT was mainly used in patients at intermediate to high BR, while DAT in those at intermediate to high TR but low BR, according to the PARIS score. Conclusion. Our data suggest that some variables associated with increased TR or BR are poorly considered in the daily practice while the use of PARIS scales could help in the implementation of guidelines' recommendations.

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