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High Major Bleeding Rates During Triple Therapy
Study Questions:
What are the rates of major bleeding among patients receiving combination antithrombotic therapies?
Methods:
The authors conducted a cohort study of Danish patients with atrial fibrillation ages ≥50 years. Incidence rates (IRs) of major bleeding and hazard ratios were estimated, stratified by specific combinations of antithrombotic medications, age, CHA2DS2-VASc score, and comorbidities. Major bleeding was defined as requiring hospitalization or resulting in death.
Results:
The authors identified 272,315 patients with atrial fibrillation, median age 75 years (interquartile range, 67-83 years), and 47% women. Over a total follow-up of 1,373,131 patient-years, 31,459 major bleeding events occurred (IR, 2.3/100-patient-years). Compared with vitamin K antagonist (VKA) monotherapy, major bleeding was more common for patients taking dual antiplatelet therapy (adjusted hazard ratio [aHR], 1.13; 95% confidence interval [CI], 1.06-1.19), VKA + single antiplatelet therapy (aHR, 1.82; 95% CI, 1.76-1.89), direct oral anticoagulant (DOAC) + single antiplatelet therapy (aHR, 1.28; 95% CI, 1.13-1.44), VKA + dual antiplatelet therapy (aHR, 3.73; 95% CI, 1.13-1.44), and DOAC + dual antiplatelet therapy (aHR, 2.28; 95% CI, 1.67-3.12). The IR for major bleeding was 10.2/100-patient-years among patients taking triple antithrombotic therapy. Major bleeding was even more common among patients ages >90 years (IR, 22.8/100-patient-years), with CHA2DS2-VASc score >6 (IR, 17.6/100-patient-years), and with a history of major bleeding (IR, 17.5/100-patient-years).
Conclusions:
The authors concluded that patients with atrial fibrillation who are treated with triple antithrombotic therapy experience high rates of major bleeding as compared to patients on single or dual antithrombotic therapy.
Perspective:
This study provides confirmatory data that use of increasing numbers of antithrombotic medications is associated with increasing risk of major bleeding events, which result in hospitalization and/or death. Recently published prospective data have begun to identify patients with atrial fibrillation and coronary artery disease who may be safely treated with single or dual antiplatelet strategies. In addition to reducing the total number and duration of antithrombotic medications, clinicians are encouraged to identify other strategies to reduce major bleeding risk (e.g., avoiding nonsteroidal anti-inflammatory drugs, judicious use of gastroprotection).
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Coronary Artery Disease, Fibrinolytic Agents, Geriatrics, Hemorrhage, Incidence, Platelet Aggregation Inhibitors, Secondary Prevention, Thrombosis, Vitamin K
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