Anticoagulation Patterns in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention in an Academic Center

Abstract

A common dilemma facing physicians treating patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) is the management of oral anticoagulation (OAC) therapy, because there is also an indication for dual antiplatelet therapy in these patients. The purpose of this study was therefore to evaluate anticoagulation patterns in this patient population in an attempt to identify patterns of risk factors that may influence OAC prescribing habits. This retrospective study entailed a review of a total of 4,648 patients from two academic hospitals who underwent PCI between 2008 and 2016. We ultimately included 211 patients who had AF and an indication for OAC. Chart review revealed patients' risk factors, CHA 2 DS 2-VASc and HAS-BLED scores, and antithrombotic regimens. Only 105 (49.8%) patients who met the indications for OAC were actually placed on OAC post-PCI. There was no significant relationship between discharge on OAC and HAS-BLED score (t = 0.14; p = 0.44) or CHA 2 DS 2-VASc score (t = 0.76; p = 0.22). Patients younger than 65 years of age were prescribed more triple therapy (56% versus 33%; p < 0.01) or any OAC (69% versus 41%; p < 0.01) on discharge in comparison with patients 65 years of age or older. The older patient group had a significantly higher average CHA 2 DS 2-VASc score (4.4 versus 3.2; p < 0.01) and a higher average HAS-BLED score (2.8 versus 2.4; p < 0.01). Ultimately, this study indicated that less than half of AF patients with an indication for OAC were placed on OAC post-PCI. There was no association between discharge on OAC and CHA 2 DS 2-VASc score, HAS-BLED score, or any other individual risk factor, with the exception of age.

Oral Anticoagulant Therapy: When What Should Not Be Is and What Should Be Is Not

“…Not uncommonly, physicians have used a fear of more elderly patients falling and suffering a head or other major injury as a reason to avoid anticoagulation. While we have no way of knowing from the Rusia et al 1 report whether this was the case in their surveyed institutions, there is literature-reported data to indicate that this concern is excessive. In 2012, Donze et al examined 515 consecutive adult medical patients discharged on an OAC.…”

“…Simply put, the oldest patients with AF are those who have the highest risk of stroke and the most to gain from anticoagulation." Second, and disturbing rather than encouraging, Rusia et al 1 found no statistical association between discharge on an OAC and CHA 2 DS 2 -VASc score, with a worrisome trend occurring in the opposite direction. A higher CHA 2 DS 2 -VASc score indicates a greater risk for thromboembolism in AF and should be associated with a higher use of OACs.…”

“…In the current issue of The Journal of Innovations in Cardiac Rhythm Management, Rusia et al report on anticoagulation patterns in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) at two academic institutions in California between 2008 and 2016. 1 Their retrospective analysis was designed to identify factors that may have influenced the appropriate use of oral anticoagulants (OACs) in this population of patients who also required antiplatelet therapy following their PCI procedure. Unfortunately, of the 4,648 patients who underwent PCI, only 211 also had AF and an indication for OAC therapy, thus making the study's dataset quite small and therefore perhaps limiting the ability for adequate interpretation.…”

“…The prevention of stroke should usually take the highest priority. Rusia et al 1 were aware of this (although their surveyed hospital physicians may not have been) when they wrote in their report: "a reduced stroke risk generally far outweighs the risk of major hemorrhage while on anticoagulation and most concerns about bleeding are generally unfounded. Simply put, the oldest patients with AF are those who have the highest risk of stroke and the most to gain from anticoagulation."…”

“…Thus, major bleeds were not statistically associated with falls, and physician determination of fall risk was not very accurate. In a more recent study 8 that examined outcomes of patients on apixaban (not discussed in the Rusia et al report 1 ) in comparison with warfarin, stratified by a history of falls or absence thereof, although patients with a history of falls had higher rates of major bleeding (hazard ratio: 1.39; p = 0.020), including intracranial bleeding (hazard ratio: 1.87; p = 0.044), in those with a history of falls, there were five subdural bleeds among 367 patients on warfarin and zero among 386 patients on apixaban. Importantly, patients with a history of falls were more likely to be female and to have a history of dementia, cerebrovascular disease, depression, diabetes, heart failure, osteoporosis, fractures, higher CHA 2 DS 2 -VASc scores, and higher HAS-BLED scores.…”