Anti-thrombotic strategies in patients with atrial fibrillation undergoing PCI

Abstract

Triple anti-thrombotic therapy combining oral anticoagulation and dual anti-platelet therapy following percutaneous coronary intervention in patients with atrial fibrillation was considered as standard and recommended by guidelines. While bleeding risk is considerable with that approach, data for efficacy are scare. Several trials assessed the possibility of reducing antithrombotic treatment by mainly shortening the exposure to acetylsalicylic acid. Dropping one of the anti-platelet components might increase the risk of stent thrombosis, myocardial infarction or stroke. Despite that fear, the recent trials' primary endpoint was major and/or clinically-relevant non-major bleeding. We review data on major bleedings, intracranial bleedings and major adverse cardiovascular events from the published reports. We demonstrate that Non-Vitamin K oral anticoagulant (NOAC)-based strategies compared to VKA-based triple therapies significantly reduce the risk for TIMI-major bleedings by 39% and for intracranial bleedings by 66%, while they did not increase the risk for overall ischemic or embolic events. However, recent meta-analyses indicate an increased risk for stent thrombosis with less intense anti-thrombotic therapy. While the overall incidence rate for stent thrombosis is rather low, relative increases by about 30-60% are reported, but they did not translate into adverse clinical net-benefit ratios. This review highlights that using certain NOAC regimens proven effective for stroke prevention in AF can reduce the rate of bleeding without increasing ischemic or embolic events. Furthermore, additive ASA in triple anti-thrombotic regimens should be limited to 1 month and individual weighing of ischemic versus bleeding risk during the first 30 days seems to be reasonable.

Duration and clinical outcome of dual antiplatelet therapy after percutaneous coronary intervention: a retrospective cohort study using a medical information database from Japanese hospitals

“…A history of MI, one of the factors associated with ischemic events in the present study, may indicate a history of PCI or coronary artery bypass graft, which are also considered risk factors for thrombosis by the JCS [ 5 ]. Furthermore, the use of anticoagulants may imply the existence of atrial fibrillation, which is another ischemic risk factor in patients undergoing PCI [ 20 , 21 ]. This result suggests that in patients with high bleeding risk, DAPT duration < 3 months may be insufficient to prevent ischemic events, particularly in patients at high ischemic risk.…”

Anticoagulants for stroke prevention in heart failure with reduced ejection fraction

“…Routine anticoagulation with VKA did not provide a clinical benefit owing to the increased rate of major bleedings and lower than expected stroke rates. In HF patients with atrial fibrillation, oral factor Xa inhibitors compared to VKA provided at least equally effective stroke prevention, but caused less serious bleeding complications similar to what has been observed in other high risk constellations such as combined antithrombotic therapies [ 44 ]. However, major bleedings still occurred in about 2% of patients per year.…”

Antithrombotische Therapie beim akuten Koronarsyndrom

“…Zur Anwendung der NOAKs in speziellen Situationen gibt es vielfältige Literatur [16]. Für alle 4 zur Schlaganfallprävention bei Vorhofflimmern zugelassenen NOAKs gibt es Kombinationsstudien mit Thrombozyten-Hemmern, die auch Patienten mit ACS eingeschlossen hatten [17]. Diesen Studien ist jedoch gemein, dass sie einen weitgefassten Blutungsendpunkt als primären Endpunkt nutzten.…”

“…Der primäre Endpunkt bezog sich entweder auf jegliche Blutung oder auf die Kombination aus schweren und sog. klinisch relevanten, nicht schweren Blutungen mit unterschiedlichen Referenzkriterien in den verschiedenen Studien [17].…”