Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients After Myocardial Infarction and Coronary Intervention

Lamberts, Morten; Gislason, Gunnar; Olesen, Jonas Bjerring; Kristensen, Søren Lund; Olsen, Anne-Marie Schjerning; Mikkelsen, A. B.; Christensen, Christine Benn; Lip, Gregory Y.H.; Køber, Lars; Torp‐Pedersen, Christian; Hansen, Morten Lock

doi:10.1016/j.jacc.2013.05.029

Cited by 321 publications

(226 citation statements)

References 31 publications

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“…The study showed that dual antithrombotic therapy significantly reduced the risk of bleeding and was also associated with a lower risk of death or thrombotic events than was triple antithrombotic therapy 19. Data from registries support the WOEST findings 19, 20. More recently, the findings from the open‐label ISAR‐TRIPLE trial,21 which involved 614 patients with an indication for OAC who were undergoing drug‐eluting stent (DES) implantation, support a limited duration (6 weeks vs 6 months) of triple antithrombotic therapy 22…”

Section: Introductionmentioning

confidence: 65%

“…As noted above, antiplatelet monotherapy is not sufficient for stroke prevention, nor is dual antiplatelet therapy alone (although this has not been tested with the more potent drugs). On the other end of the spectrum, use of triple antithrombotic therapy for 1 year has an unacceptable increased risk of bleeding 13, 20, 36…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, because blockade of P2Y 12 receptor–mediated signaling with clopidogrel is associated with greater platelet‐inhibitory effects than cyclooxygenase‐1 inhibition with aspirin, as well as the established role of P2Y 12 receptor blockade on recurrent thrombotic events, clopidogrel might be expected to be more effective than aspirin at reducing risk of ST, with a potentially lower rate of gastrointestinal bleeding as well 40. A few retrospective cohorts have observed a lower incidence of ST with clopidogrel plus warfarin dual antithrombotic therapy,13, 20, 41 and clopidogrel, aspirin, and warfarin triple antithrombotic therapy,42 compared with warfarin and aspirin dual antithrombotic therapy.…”

Section: Discussionmentioning

confidence: 99%

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Design and Rationale of the RE‐DUAL PCI Trial: A Prospective, Randomized, Phase 3b Study Comparing the Safety and Efficacy of Dual Antithrombotic Therapy With Dabigatran Etexilate Versus Warfarin Triple Therapy in Patients With Nonvalvular Atrial Fibrillation Who Have Undergone Percutaneous Coronary Intervention With Stenting

Cannon

Gropper

Bhatt

et al. 2016

Clinical Cardiology

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Antithrombotic management of patients with atrial fibrillation (AF) undergoing coronary stenting is complicated by the need for anticoagulant therapy for stroke prevention and dual antiplatelet therapy for prevention of stent thrombosis and coronary events. Triple antithrombotic therapy, typically comprising warfarin, aspirin, and clopidogrel, is associated with a high risk of bleeding. A modest‐sized trial of oral anticoagulation with warfarin and clopidogrel without aspirin showed improvements in both bleeding and thrombotic events compared with triple therapy, but large trials are lacking. The RE‐DUAL PCI trial (NCT 02164864) is a phase 3b, a strategy of prospective, randomized, open‐label, blinded‐endpoint trial. The main objective is to evaluate dual antithrombotic therapy with dabigatran etexilate (110 or 150 mg twice daily) and a P2Y12 inhibtor (either clopidogrel or ticagrelor) compared with triple antithrombotic therapy with warfarin, a P2Y12 inhibtor (either clopidogrel or ticagrelor, and low‐dose aspirin (for 1 or 3 months, depending on stent type) in nonvalvular AF patients who have undergone percutaneous coronary intervention with stenting. The primary endpoint is time to first International Society of Thrombosis and Hemostasis major bleeding event or clinically relevant nonmajor bleeding event. Secondary endpoints are the composite of all cause death or thrombotic events (myocardial infarction, or stroke/systemic embolism) and unplanned revascularization; death or thrombotic events; individual outcome events; death, myocardial infarction, or stroke; and unplanned revascularization. A hierarchical procedure for multiple testing will be used. The plan is to randomize ∼ 2500 patients at approximately 550 centers worldwide to try to identify new treatment strategies for this patient population.

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Section: Introductionmentioning

confidence: 65%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Design and Rationale of the RE‐DUAL PCI Trial: A Prospective, Randomized, Phase 3b Study Comparing the Safety and Efficacy of Dual Antithrombotic Therapy With Dabigatran Etexilate Versus Warfarin Triple Therapy in Patients With Nonvalvular Atrial Fibrillation Who Have Undergone Percutaneous Coronary Intervention With Stenting

Cannon

Gropper

Bhatt

et al. 2016

Clinical Cardiology

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“…From 625 initial citations, 16 eligible studies including a total of 9185 patients were identified in the present meta‐analysis,4, 5, 6, 7, 12, 14, 15, 19, 20, 21, 22, 23, 24, 25, 26, 27 with 5680 patients in the triple therapy group and 3505 in the dual therapy group (Figure 1). …”

Section: Resultsmentioning

confidence: 99%

“…Finally, 12 studies were identified in the DAPT subgroup,4, 5, 6, 7, 19, 20, 21, 22, 23, 24, 25, 26 with the other 4 studies included in the OAC/C subgroup 12, 14, 15, 27…”

Section: Resultsmentioning

confidence: 99%

Antithrombotic Regimens for Patients Taking Oral Anticoagulation After Coronary Intervention: A Meta‐analysis of 16 Clinical Trials and 9185 Patients

Gao

Chen

Fan

et al. 2015

Clinical Cardiology

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The optimal antithrombotic regimen remains controversial in patients taking oral anticoagulation (OAC) undergoing coronary stenting. This study sought to compare efficacy and safety outcomes of triple therapy (OAC, aspirin, and clopidogrel) vs dual therapy (clopidogrel with aspirin or OAC) in these patients. We hypothesize OAC plus clopidogrel could be the optimal regimen for patients with indications for OAC receiving stent implantation. Medline, the Cochrane Library, and other Internet sources were searched for clinical trials comparing the efficacy and safety of triple vs dual therapy for patients taking OAC after coronary stenting. Sixteen eligible trials including 9185 patients were identified. The risks of major adverse cardiac events (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 0.82‐1.39, P = 0.65), all‐cause mortality (OR: 0.98, 95% CI: 0.76‐1.27, P = 0.89), myocardial infarction (OR: 1.01, 95% CI: 0.77‐1.31, P = 0.97), and stent thrombosis (OR: 0.91, 95% CI: 0.49‐1.69, P = 0.75) were similar between triple and dual therapy. Compared with dual therapy, triple therapy was associated with a reduced risk of ischemic stroke (OR: 0.57, 95% CI: 0.35‐0.94, P = 0.03) but with higher major bleeding (OR: 1.52, 95% CI: 1.11‐2.10, P = 0.01) and minor bleeding (OR: 1.59, 95% CI: 1.05‐2.42, P = 0.03). Subgroup analysis indicated there were similar ischemic stroke and major bleeding outcomes between triple therapy and therapy with OAC plus clopidogrel. Treatment with OAC and clopidogrel was associated with similar efficacy and safety outcomes compared with triple therapy. Triple therapy could be replaced by OAC plus clopidogrel without any concern about additional risk of thrombotic events.

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Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation

et al. 2020

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IMPORTANCE Patients with nonvalvular atrial fibrillation at risk of stroke should receive oral anticoagulants (OAC). However, approximately 1 in 8 patients in the Global Anticoagulant Registry in the Field (GARFIELD-AF) registry are treated with antiplatelet (AP) drugs in addition to OAC, with or without documented vascular disease or other indications for AP therapy. OBJECTIVE To investigate baseline characteristics and outcomes of patients who were prescribed OAC plus AP therapy vs OAC alone.

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Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients After Myocardial Infarction and Coronary Intervention

Abstract: In real-life AF patients with indication for multiple antithrombotic drugs after MI/PCI, OAC and clopidogrel was equal or better on both benefit and safety outcomes compared to triple therapy.

Cited by 321 publications

References 31 publications

Antithrombotic Regimens for Patients Taking Oral Anticoagulation After Coronary Intervention: A Meta‐analysis of 16 Clinical Trials and 9185 Patients

Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation

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