AF Outcomes in Patients With Drug-Eluting Stents

Study Questions:

What is the optimal antithrombotic strategy in patients with a drug-eluting stent (DES) and atrial fibrillation (AF)?

Methods:

This was an observational cohort study of 10,027 registry patients (mean age 62 years) who received a DES. The primary outcome was a composite of cardiovascular death, myocardial infarction, or stroke.

Results:

At the time of DES implantation, 711 patients (7.1%) had a diagnosis of AF. The majority of patients with AF (88.4%) were treated with dual antiplatelet therapy (DAPT; aspirin plus clopidogrel) and 11.6% received triple therapy (DAPT plus warfarin). At 6 years of follow-up, the primary outcome was significantly higher in the AF patients (22.1%) than in the non-AF patients (8.0%). Among the AF patients, the primary outcome did not differ between the patients treated with DAPT versus triple therapy. Compared with DAPT, triple therapy was associated with a 7.7-fold higher risk of hemorrhagic stroke and a 4.5-fold higher risk of major bleeding.

Conclusions:

The use of triple therapy in patients with AF and a DES does not lower the risk of cardiovascular mortality or ischemic events, but increases the risk of major bleeding and hemorrhagic stroke.

Perspective:

A major problem with this study is that the duration of clopidogrel treatment was at the physician’s discretion and 24% of patients in the triple therapy group were still receiving this agent at 5 years of follow-up. Furthermore, the study did not include patients treated with warfarin plus clopidogrel without aspirin. Prior studies have reported conflicting results and currently ongoing studies are evaluating the novel oral anticoagulants in combination with antiplatelet therapy. For now, the optimal antithrombotic strategy in patients with AF and a DES remains unclear.

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

Keywords: Anticoagulants, Arrhythmias, Cardiac, Aspirin, Atrial Fibrillation, Drug-Eluting Stents, Hemorrhage, Ischemia, Myocardial Infarction, Platelet Aggregation Inhibitors, Stents, Stroke, Treatment Outcome, Warfarin


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