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Anticoagulant + Antiplatelet Therapy in AF + Coronary Disease
Study Questions:
What are the risks of adverse events for patients with atrial fibrillation (AF) and myocardial infarction (MI) or percutaneous coronary intervention (PCI) taking an anticoagulant in addition to antiplatelet therapy?
Methods:
The authors used Danish nationwide registries to identify patients with AF who were hospitalized for MI and/or PCI between August 2011 and June 2017. They studied the patients treated with combinations of oral anticoagulants and antiplatelet medications. Patients were followed for 12 months. Standardized absolute risks were assessed at 3 and 12 months of follow-up.
Results:
Of the 3,222 patients in the study population, 875 (27%) received vitamin K antagonist (VKA) plus a single antiplatelet, 595 (18%) received a direct oral anticoagulant (DOAC) plus single antiplatelet, 1,074 (22%) received VKA plus dual antiplatelet therapy (DAPT), and 678 (22%) received DOAC plus DAPT. At 3 months, there was a lower risk of MI in DOAC vs. VKA plus single antiplatelet (absolute risk difference, -1.53%; 95% confidence interval [CI], -3.08% to -0.11%). No difference was found for bleeding, ischemic stroke, and all-cause mortality. In adjusted models, there was a trend towards a lower risk of MI for DOAC vs. VKA treated in addition to single antiplatelet therapy (adjusted hazard ratio [aHR], 0.63; 95% confidence interval [CI], 0.40-1.00). At 3 months, the risk of bleeding was lower for DOAC vs. VKA plus DAPT (absolute risk difference, -1.96%; 95% CI, -3.46% to -0.88%). There was no difference in the risk of all-cause mortality, stroke, or MI. For patients with DAPT, use of DOAC was associated with a reduced risk of bleeding (aHR, 0.51; 95% CI, 0.33-0.78) with similar risks of ischemic stroke, MI, and all-cause mortality.
Conclusions:
The authors concluded that use of DOAC as compared to VKA reduced the risk of bleeding in patients also taking DAPT.
Perspective:
This study examines an increasingly important and common clinical question. Within the limitations of a nonrandomized, retrospective study, they demonstrate overall safety of DOAC therapy as compared to VKA for patients with AF who are also treated with antiplatelet therapy for MI and/or PCI. It is notable that bleeding risk is reduced for DOAC plus DAPT, while MI risk is reduced for DOAC plus single antiplatelet therapy. Prior randomized trials have focused on the question of single vs. DAPT for AF and PCI patients, but have primarily used VKA anticoagulation. This study suggests that DOAC therapy may be beneficial in select populations, especially those at increased risk for bleeding who require DAPT following PCI in addition to an oral anticoagulant for AF.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Coronary Disease, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Primary Prevention, Risk, Stroke, Vascular Diseases
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