Antithrombotic treatment in patients with atrial fibrillation after percutaneous coronary intervention, a difficult balance to achieve
DOI:
https://doi.org/10.19230/jonnpr.4435Keywords:
antithrombotic treatment; atrial fibrillation; coronary intervention percutaneousAbstract
The combination of antithrombotic treatment (anticoagulant / antiplatelet) that those who
AF patients who have ACS and / or must undergo PCI is unclear. The association of
oral anticoagulation with a P2Y 12 inhibitor and aspirin, called triple antithrombotic therapy
(TAT) is associated with a high risk of bleeding. On the other hand, dual antithrombotic therapy (DAT) without
Aspirin carries a still unknown risk of ischemic events. (1) Treatment must balance the
ischemic and hemorrhagic risk reaching an optimal net clinical benefit. The purpose of this review
is to establish clearer treatment guidelines in these patients. We analyzed 2 previous observational studies to establish the starting point and 5 RCTs that included a total of 11,532 patients.
In them, DAT vs. TAT, in patients with AF who suffer from ACS and / or undergo PCI.
DAT was associated with a lower rate of bleeding compared to TAT without increasing ischemic events. Without
However, no trial achieved sufficient statistical power to consistently assess the
ischemic efficacy results. Of the different therapies, they showed better efficacy results
those that used DAT versus TAT ??and ACOD versus VKA. Conclusion: In patients with AF who
suffer an ACS and / or must undergo PCI, the DAT regimen associates fewer bleeding events, without
significant differences regarding ischemic events; The use of ACOD shows a better profile of
benefit versus AVK, so they are preferred.
Downloads
References
Haller PM, Sulzgruber P, Kaufmann C, et al. Bleeding and ischaemic outcomes in patients treated with dual or triple antithrombotic therapy: systematic review and meta-analysis. Eur Heart J Cardiovasc Pharmacother 2019;5(4):226–36.
Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2020;
Kasper D, Fauci A, Hauser S, Longo D, Jameson JL, Loscalzo J. HARRISON MANUAL DE MEDICINA INTERNA. 2017.
Benjamin EJ, Muntner P, Alonso A, et al. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019;139(10):e56–528.
Gómez-Doblas JJ, López-Garrido MA, Esteve-Ruiz I, Barón-Esquivias G. Epidemiología de la fibrilación auricular. Rev Esp Cardiol 2016;16:2–7.
Excelente LP-S. Proceso Fibrilación Auricular [Internet]. Soc. Esp. Cardiol. [cited 2020 Dec 14];Available from: https://secardiologia.es/institucional/reuniones-institucionales/sec- calidad/sec-excelente/procesos/8711-proceso-fibrilacion-auricular
Pérez-Copete J, Esteve-Pastor MA, Roldán V, Valdés M, Marín F. Escalas de evaluación del riesgo tromboembólico y hemorrágico en la fibrilación auricular. Rev Esp Cardiol 2016;16:25–32.
Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010;137(2):263–72.
Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet Lond Engl 2014;383(9921):955–62.
Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009;361(12):1139–51.
Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365(10):883–91.
Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365(11):981–92.
Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013;369(22):2093–104.
Defunciones por causas (lista reducida) por sexo y grupos de edad(7947) [Internet]. INE. [cited 2020 Dec 14];Available from: https://www.ine.es/jaxiT3/Tabla.htm?t=7947
2018 ESC/EACTS Guidelines on Myocardial Revascularization [Internet]. Soc. Esp. Cardiol. [cited 2020 Dec 14];Available from: https://secardiologia.es/cientifico/guias-clinicas/cardiopatia- isquemica/10909-2018-esc-eacts-guidelines-on-myocardial-revascularization
Le Quellec S, Bordet J-C, Negrier C, Dargaud Y. Comparison of current platelet functional tests for the assessment of aspirin and clopidogrel response. A review of the literature. Thromb Haemost 2016;116(4):638–50.
Galli M, Andreotti F, Porto I, Crea F. Intracranial haemorrhages vs. stent thromboses with direct oral anticoagulant plus single antiplatelet agent or triple antithrombotic therapy: a meta-analysis of randomized trials in atrial fibrillation and percutaneous coronary intervention/acute coronary syndrome patients. Eur Eur Pacing Arrhythm Card Electrophysiol J Work Groups Card Pacing Arrhythm Card Cell Electrophysiol Eur Soc Cardiol 2020;22(4):538–46.
Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151(4):264–9, W64.
Lamberts M, Gislason GH, Olesen JB, et al. Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. J Am Coll Cardiol 2013;62(11):981–9.
D’Ascenzo F, Taha S, Moretti C, et al. Meta-analysis of randomized controlled trials and adjusted observational results of use of clopidogrel, aspirin, and oral anticoagulants in patients undergoing percutaneous coronary intervention. Am J Cardiol 2015;115(9):1185–93.
Fiedler KA, Maeng M, Mehilli J, et al. Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After Drug-Eluting Stent Implantation: The ISAR-TRIPLE Trial. J Am Coll Cardiol 2015;65(16):1619–29.
Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. The Lancet 2013;381(9872):1107–15.
Gibson CM, Mehran R, Bode C, et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med 2016;375(25):2423–34.
Cannon CP, Bhatt DL, Oldgren J, et al. Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation. N Engl J Med 2017;377(16):1513– 24.
Lopes RD, Heizer G, Aronson R, et al. Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation. N Engl J Med 2019;380(16):1509–24.
Vranckx P, Valgimigli M, Eckardt L, et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. The Lancet 2019;394(10206):1335–43.
ACTIVE Writing Group of the ACTIVE Investigators, Connolly S, Pogue J, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet Lond Engl 2006;367(9526):1903–12.
Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365(11):981–92.
Oldgren J, Steg PG, Hohnloser SH, et al. Dabigatran dual therapy with ticagrelor or clopidogrel after percutaneous coronary intervention in atrial fibrillation patients with or without acute coronary syndrome: a subgroup analysis from the RE-DUAL PCI trial. Eur Heart J 2019;40(19):1553–62.
Kuno T, Ueyama H, Ando T, Briasoulis A, Takagi H. Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention; insights from a meta- analysis. Coron Artery Dis 2021;32(1):31–5.
Khan SU, Osman M, Khan MU, et al. Dual Versus Triple Therapy for Atrial Fibrillation After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis. Ann Intern Med 2020;172(7):474–83.
Lopes RD, Hong H, Harskamp RE, et al. Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Network Meta-analysis of randomized Controlled Trials. JAMA Cardiol 2019;4(8):747–55.
Gargiulo G, Goette A, Tijssen J, et al. Safety and efficacy outcomes of double vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials. Eur Heart J
Published
Issue
Section
License
All accepted originals remain the property of JONNPR. In the event of publication, the authors exclusively transfer their rights of reproduction, distribution, translation and public communication (by any sound, audiovisual or electronic medium or format) of their work. To do so, the authors shall sign a letter transferring these rights when sending the paper via the online manuscript management system.
The articles published in the journal are freely used under the terms of the Creative Commons BY NC SA license, therefore.
You are free to:
Share — copy and redistribute the material in any medium or format
Adapt — remix, transform, and build upon the material
The licensor cannot revoke these freedoms as long as you follow the license terms.
Under the following terms:
Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
NonCommercial — You may not use the material for commercial purposes.
ShareAlike — If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original.
No additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
