scholarly journals Antithrombotic strategy in patients with atrial fibrillation and acute coronary syndrome

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
I Almeida ◽  
H Santos ◽  
M Santos ◽  
H Miranda ◽  
J Chin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Antithrombotic Therapy ◽  
De Novo ◽  
Vitamin K Antagonists ◽  
Antiplatelet Agent ◽  
P2y12 Inhibitors ◽  
Coronary Syndrome ◽  
Short Period ◽  
St Elevation

Abstract Background Atrial fibrillation (AF) is frequent in patients admitted with acute coronary syndromes (ACS). The development of this arrhythmia occurs in 2–21% of patients with non ST-elevation ACS and 21% of ST-elevation ACS. According with the most recent European guidelines, a short period up to 1 week of triple antithrombotic therapy (TAT) is recommended, followed by dual antithrombotic therapy (DAT) using a NOAC and a single antiplatelet agent, preferably clopidogrel. Objective To compare the antithrombotic strategy (DAT vs TAT) used and its prognostic value in patients with AF and ACS. Methods Retrospective analysis of patients' data admitted with ACS in a multicentric registry between 10/2010–09/2019. TAT was defined as the prescription of dual antiplatelet therapy and one anticoagulant and DAT as one antiplatelet and one anticoagulant. Survival and rehospitalization were evaluated through Kaplan-Meier curve. Results 1067 patients were included, mean age 67±14 years, 72.3% male. Patients who developed de novo AF during hospitalization due to ACS were older (75±12 vs 66±14 years, p<0.001) and with higher prevalence of cardiovascular risk factors and cardiovascular disease. AF was more often in patients with ST elevation ACS (53.4%). During hospitalization, AF patients were more often medicated with aspirin, glycoprotein inhibitor, heparin, fondaparinux and vitamin K antagonists. No difference was found regarding P2Y12 inhibitors. AF patients presented more often obstructive coronary disease (normal coronaries 5.4 vs 8.5%, p<0.001) so they were more often submitted to PCI (79.5 vs 70.9%, p<0.001). AF patients presented with higher rates of adverse in-hospital events as re-infarction, heart failure, shock, ventricular arrhythmias, cardiac arrest, stroke, major bleeding and death (p<0.001). At discharge, AF patients were less prescribed with aspirin or ticagrelor, but the rate of clopidogrel prescription was higher, such as vitamin K antagonists or any of the new anticoagulants. In the AF group, 21.5% patients were discharged with TAT and 30.3% with DAT. Concerning patients discharged with TAT, 1-year follow-up revealed no significant differences in mortality (p=0.578), re-admission for cardiovascular causes (p=0.301) and total re-admission rates (p=0.291). Patients discharged with DAT had similar mortality (p=0.623) and re-admission for cardiovascular causes rates (p=0.138), but significant differences were identified regarding total re-admissions (p=0.024). Conclusions In patients with ACS and de novo AF, a low percentage of patients was discharged with oral anticoagulation (51.8%). In those whose anticoagulation was initiated, DAT was the preferred strategy. 1-year outcomes were not different between the antithrombotic strategy, except for all cause re-admission. FUNDunding Acknowledgement Type of funding sources: None.

High platelet reactivity – the challenge of prolonged anticoagulation therapy after ACSI

2013 ◽  
Vol 109 (05) ◽  
pp. 799-807 ◽  
Author(s):  
Marc A. Brouwer ◽  
Freek W. A. Verheugt ◽  
Jeroen Focks
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Adjunctive Therapy ◽  
Platelet Reactivity ◽  
Vitamin K Antagonists ◽  
Antiplatelet Agent ◽  
Anticoagulation Therapy ◽  
High Platelet Reactivity ◽  
Coronary Syndrome ◽  
The Impact

SummaryDespite dual antiplatelet therapy (DAPT), one-year event rates after acute coronary syndrome (ACS) vary from 9–12%. The development of novel oral anticoagulants (NOAC) without a need for monitoring has initiated renewed interest for prolonged adjunctive anticoagulation. Importantly, the cornerstone of treatment after ACS consists of long-term DAPT. In that context, the NOACs have only been tested as adjunctive therapy. Of all new agents, only rivaroxaban –in a substantially lower dose than used for atrial fibrillation– has been demonstrated to improve outcome, albeit at the cost of bleeding. In selected cases, adjunctive therapy with dose-adjusted vitamin-K antagonists (international normalized ratio [INR] 2.0–3.0) can be considered as well. These two strategies of prolonged anticoagulation can be considered in case of ‘high platelet reactivity’, i.e. in patients at high risk of recurrent thrombotic events despite DAPT. Both during admission and after discharge for ACS, the use of NOACs in doses indicated for atrial fibrillation is strictly contra-indicated in patients on DAPT. In case of post-discharge anticoagulation therapy for atrial fibrillation, patients should preferably receive vitamin-K antagonists (INR 2.0–3.0), with discontinuation of one antiplatelet agent as soon as clinically justifiable. Importantly, the impact of prolonged anticoagulation (low-dose rivaroxaban, vitamin-K antagonists) as adjunctive to DAPT after ACS has not been addressed with the most potent antiplatelet agents (prasugrel, ticagrelor) and merits further study. Despite the potential indication of prolonged oral anticoagulation as adjunctive treatment, it remains to be established whether anticoagulation therapy could also be an alternative for either aspirin or thienopyridine treatment in selected ACS patients on DAPT.

scholarly journals Apixaban or Vitamin K Antagonists and Aspirin or Placebo According to Kidney Function in Patients with Atrial Fibrillation After Acute Coronary Syndrome or PCI: Insights from The AUGUSTUS Trial

Circulation ◽  
2021 ◽  
Author(s):  
Ziad Hijazi ◽  
John H. Alexander ◽  
Zhuokai Li ◽  
Daniel M. Wojdyla ◽  
Roxana Mehran ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Kidney Function ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Exclusion Criterion ◽  
Risk Of Death ◽  
Coronary Syndrome ◽  
Risk Of Bleeding ◽  
Ischemic Events

Background: In the AUGUSTUS trial, apixaban resulted in less bleeding and fewer hospitalizations than vitamin K antagonists (VKA), and aspirin caused more bleeding than placebo in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention treated with a P2Y 12 inhibitor. We evaluated the risk-benefit balance of antithrombotic therapy according to kidney function. Methods: In 4456 patients, the CKD-EPI formula was used to calculate baseline estimated glomerular filtration rate (eGFR). The effect of apixaban vs. VKA and aspirin vs. placebo was assessed across kidney function categories using Cox models. The primary outcome was ISTH major or clinically relevant non-major bleeding. Secondary outcomes included death or hospitalization and ischemic events (death, stroke, myocardial infarction, stent thrombosis [definite or probable], or urgent revascularization). Creatinine clearance below 30 mL/min was an exclusion criterion in the AUGUSTUS trial. Results: Overall, 30%, 52%, and 19% had an eGFR of >80, >50 to 80, and 30-50 mL/min/1.73m 2 , respectively. During 6-months follow-up a total of 543 primary outcomes of bleeding, 1125 death or hospitalizations, and 282 ischemic events occurred. Compared with VKA, patients assigned apixaban had lower rates for all 3 outcomes across most eGFR categories without significant interaction. The absolute risk reduction with apixaban was most pronounced in those with an eGFR of 30-50 mL/min/1.73m 2 for bleeding events with rates of 13.1% vs. 21.3%; HR (95% CI) 0.59 (0.41-0.84). Patients assigned aspirin had a higher risk of bleeding in all eGFR categories with an even greater increase among those with eGFR >80 mL/min/1.73m 2 : 16.6% vs. 5.6%; HR 3.22 (2.19-4.74); p for interaction=0.007). The risk of death or hospitalization and ischemic events were comparable with aspirin and placebo across eGFR categories with HR ranging from 0.97 (0.76-1.23) to 1.28 (1.02-1.59) and from 0.75 (0.48-1.17) to 1.34 (0.81-2.22), respectively. Conclusions: The safety and efficacy of apixaban was consistent irrespective of kidney function, as compared with warfarin, and in accordance with the overall trial results. The risk of bleeding with aspirin was consistently higher across all kidney function categories. Clinical Trial Registration: URL: https://www.clinicaltrials.gov Unique Identifier: NCT02415400

Antithrombotische Therapie bei akutem Koronarsyndrom und Vorhofflimmern

2020 ◽  
Vol 145 (14) ◽  
pp. 978-986
Author(s):  
Harald Darius
Keyword(s):  
Triple Therapy ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Antiplatelet Agent ◽  
Current Status ◽  
Bleeding Complications ◽  
Coronary Syndrome ◽  
Coronary Stent Implantation ◽  
Number Of Patients

AbstractThe number of patients with atrial fibrillation (AF) is increasing due to the aging of the population. In addition, the number of patients with AF and an indication for oral anticoagulation (OAC) for the prevention of strokes increases, who are in need for a dual antiplatelet therapy (DAPT) with acetyl salicylic acid (ASA) plus a P2Y12-Inhibitor because of an acute coronary syndrome and/or coronary stent implantation. These patients did receive a triple therapy (TT) for 3–12 months in the past. Triple therapy never has been studied for efficacy or safety, however, the rate of bleeding complications in comparison to OAC or DAPT is significantly higher.Registries and smaller trials showed that dual therapy with an OAC plus a single platelet inhibitor may be sufficient to prevent strokes and stent thromboses/myocardial infarctions. Four prospective randomized trials involving all four NOACs (Non-Vitamin K oral anticoagulants) approved for stroke prevention in AF have been undertaken. The NOACs plus one antiplatelet agent were tested versus vitamin K-antagonists plus DAPT. In the meantime, the trials involving rivaroxaban (PIONEER AF-PCI), dabigatran (RE-DUAL PCI), apixaban (AUGUSTUS), and edoxaban (ENTRUST-AF-PCI) have been published. The current status is that a NOAC plus a single antiplatelet agent, mostly clopidogrel, is superior to TT with respect to the bleeding complications, without any obvious and statistically significant disadvantage for stroke rates or cardiac ischemic events. The international guidelines already recommend to treat with a NOAC and one antiplatelet agent instead of TT in case the patients bleeding risk is prevailing. Thus, TT seems not to be indicated anymore for most patients with AF and ACS or PCI.

scholarly journals Stroke prevention for non-valvular atrial fibrillation: how to make the right choice of directly acting oral anticoagulants?

2019 ◽  
pp. 94-102
Author(s):  
N. N. Kryukov ◽  
E. V. Sayutina ◽  
A. M. Osadchuk ◽  
M. A. Osadchuk
Keyword(s):  
Atrial Fibrillation ◽  
High Risk ◽  
Vitamin K ◽  
Randomized Clinical Trials ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Vitamin K Antagonist ◽  
Individual Risk ◽  
Stroke Risk Factor ◽  
Coronary Syndrome

Patients with atrial fibrillation have a high risk of developing stroke and death, which requires constant anticoagulant support. In this regard, the physician faces the difficult task of selecting the appropriate oral anticoagulant for patient with individual risk factors and comorbidities. Currently, three non-vitamin K antagonist oral anticoagulants or directly acting oral anticoagulants have been registered in the Russia, which in large randomized clinical trials (RCTs) were compared with warfarin in the prevention of stroke and systemic embolism. The present article analyzes the data of RCTs, postmarketing studies of oral anticoagulants, and presents groups of patients for whom these drugs are preferred. The choice of oral anticoagulants for the prevention of stroke in the following subgroups of patients with atrial fibrillation is discussed: patients with one stroke risk factor (CHA2DS2VASc1 in men or 2 in women), patients of different age groups, patients with concomitant coronary artery disease/acute coronary syndrome, a history of stroke, patients with chronic kidney disease, patients with a high risk of gastrointestinal bleeding, and a group of patients with concomitant arterial hypertension and chronic heart failure. We compared the efficacy and safety of oral non-vitamin K antagonist oral anticoagulants or directly acting oral anticoagulants with vitamin K antagonists in patients with non-valvular atrial fibrillation.

scholarly journals Double Antithrombotic versus Triple Antithrombotic Therapy in Patients with Atrial Fibrillation and Acute Coronary Syndrome

2020 ◽  
Vol 29 (02) ◽  
pp. 081-087
Author(s):  
Surya Dharma
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Vitamin K ◽  
Antithrombotic Therapy ◽  
Randomized Clinical Trials ◽  
Bleeding Event ◽  
Vitamin K Antagonist ◽  
Thromboembolic Complications ◽  
Coronary Syndrome ◽  
Triple Antithrombotic Therapy

AbstractIn atrial fibrillation (AF), oral anticoagulant (OAC) therapy with either vitamin K antagonist or non–vitamin K antagonist is used to prevent thromboembolic complications. In patients who presented with acute coronary syndrome (ACS) and were treated by percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor reduces major adverse cardiac events (MACEs) and stent thrombosis. Consequently, in patients with AF who presented with ACS and were treated by PCI, the combination of OAC and DAPT, the so-called triple antithrombotic therapy (TAT) is needed to improve the outcome of the patients. However, the use of TAT increases the risk of bleeding. Several randomized clinical trials and a meta-analysis evaluated the use of TAT and double antithrombotic therapy (DAT) in this population, and DAT is defined as patients who receive combination of one antiplatelet and OAC. In general, the studies demonstrated a reduction in bleeding event in patients who received DAT as compared with TAT, with similar incidence of thromboembolic complications and MACE. To date, there is no established consensus or guideline for the most appropriate combination of antithrombotic agents in patients with AF and ACS who undergo PCI. Tailoring the treatment for each individual is likely the best approach to determine the balance of bleeding risk and ischemic events before starting antithrombotic therapy. Future trials with adequate sample size are needed to find the most appropriate combination of antiplatelet and OAC in patients with AF who presented with ACS and treated by PCI.

scholarly journals Atherothrombotic stroke in non-valvular atrial fibrillation

2019 ◽  
Vol 11 (3S) ◽  
pp. 78-81 ◽  
Author(s):  
I. S. Yavelov ◽  
E. Yu. Okshina
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Antithrombotic Therapy ◽  
Detection Rate ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Low Risk ◽  
Antiplatelet Drugs ◽  
Hemorrhagic Complications ◽  
Poor Outcomes

The review analyzes data on the detection rate of and the abilities to predict and prevent non-cardioembolic strokes in non-valvular atrial fibrillation. According to accumulated facts, vitamin K antagonists in non-valvular atrial fibrillation are noted to be inferior to antiplatelet drugs in efficiency in preventing non-cardioembolic (atherothrombotic in particular) strokes, and the widespread use of oral anticoagulants in combination with antiplatelet drugs does not generally reduce the incidence of poor outcomes, markedly increasing the risk of serious bleeding. Nevertheless, it is conceivable that this combination antithrombotic therapy may be useful for certain categories of patients at the highest risk for atherothrombotic stroke and at relatively low risk for hemorrhagic complications. Cohorts of patients, to whom such an approach should be reasonable considered to be applied, have not yet been identified.

Sign in / Sign up

Export Citation Format

Share Document