Antithrombotic Therapy and Outcomes After ICD Implantation in Patients With AFib and CAD | Journal Scan

Study Questions:

What are the practice patterns and outcomes of patients with atrial fibrillation (AF) and coronary artery disease (CAD) undergoing implantable cardioverter-defibrillator (ICD) implantation?

Methods:

Using data from the NCDR ICD Registry linked to Medicare claims data, 25,180 patients with concurrent AF and CAD who were undergoing ICD implantation were identified. Patients were grouped based on the number of oral antiplatelet agents and use of warfarin at hospital discharge. Adjusted Cox proportional hazard modeling was used to assess for bleeding, thromboembolic events, and device-related complications after adjustment for baseline characteristics.

Results:

Among patients with AF and CAD discharged after an ICD implantation, 9,952/25,180 (39.5%) patients were discharged without warfarin therapy despite having a CHA2DS2-VASc score ≥2. Patients with a recent percutaneous coronary intervention (PCI) (within 3 months) were more likely to be discharged on dual antiplatelet therapy than patients with a more remote PCI history or no PCI history. A higher risk of 30-day bleeding events was found in patients with dual antiplatelet (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.03-1.87), warfarin plus a single antiplatelet agent (HR, 1.32; 95% CI, 1.03-1.69), and warfarin plus dual antiplatelet agents (HR, 2.03; 95% CI, 1.49-2.77) as compared to warfarin-only therapy. Major adverse cardiovascular event risk was elevated in patients discharged on a single antiplatelet agent (HR, 1.69; 95% CI, 1.33-2.16), dual antiplatelet agents (HR, 2.17; 95% CI, 1.66-2.83), and dual antiplatelet plus warfarin (HR, 1.61; 95% CI, 1.16-2.24) as compared to warfarin-only therapy. There was no association between antithrombotic agent use and thromboembolic events or device-related complications.

Conclusions:

The authors concluded that short-term bleeding risk and major adverse cardiovascular events differ between the number and type of antithrombotic agents used in patients with concurrent AF and CAD undergoing ICD implantation. The risk of thromboembolic events and device-related complications did not differ between the number of antithrombotic agents used.

Perspective:

The authors describe the use of oral antithrombotic agents in patients with concurrent AF and CAD undergoing ICD implantation. They identified low use of warfarin in high stroke-risk patients. They also identified an increased risk of bleeding and cardiovascular events without a difference in thromboembolic or device-related complication risk among patients using antithrombotic agents with or without warfarin therapy. Of important note is that patients on ‘triple therapy’ of warfarin plus dual antiplatelet agents had an increased risk of bleeding and major adverse cardiac events without any change in the risk of thromboembolic complications (e.g., stroke) as compared to warfarin-only treated patients. While these results are not conclusive in their own right, they do add to the growing evidence that use of ‘triple antithrombotic therapy’ may cause more harm than benefit. Clinicians should strongly consider that the risks might outweigh the benefits of combining multiple antithrombotic agents in their patients with concurrent AF and CAD.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Coronary Artery Disease

Keywords: Defibrillators, Implantable, Coronary Artery Disease, Anticoagulants, Fibrinolytic Agents, Warfarin, Hemorrhage, Atrial Fibrillation, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, National Cardiovascular Data Registries, ICD Registry, Secondary Prevention


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