Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI

Gibson, C. Michael; Mehran, Roxana; Bode, Christoph; Halperin, Jonathan L.; Verheugt, Freek W.A.; Wildgoose, Peter; Birmingham, Mary C.; Ianus, Juliana; Burton, Paul; Eickels, Martin van; Korjian, Serge; Daaboul, Yazan; Lip, Gregory Y.H.; Cohen, Marc; Husted, Steen; Peterson, Eric D.; Fox, Keith A.A.

doi:10.1056/nejmoa1611594

Cited by 1,348 publications

(1,192 citation statements)

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“…Especially in a setting of triple treatment (DAPT plus oral anticoagulation) (86)(87)(88), which is a separate issue that is discussed in detail elsewhere (64), a number of studies including ACS patients are ongoing that implement different NOACs with different antiplatelet treatment regimens. In addition, advancements in device technologies (latest generation drug-eluting stents) may also allow for a significant shortening (1 month) of dual antiplatelet treatment in patients with increased bleeding risk (e. g. patients who undergo PCI and need oral anticoagulation) (89).…”

Section: The Futurementioning

confidence: 99%

Antithrombotic therapy for acute coronary syndrome: Past, present and future

Sibbing

Angiolillo²,

Huber³

2017

Thromb Haemost

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SummaryPlaque erosions and ruptures are the histopathological hallmarks of arterial thrombus formation in the coronary arteries. The clinical condition associated with this process is usually referred to as acute coronary syndrome (ACS). Importantly, both blood platelets and the coagulation cascade are key players for initiation, amplification and perpetuation of ACS. There has been great progress in ACS treatment in recent decades, both at the technical level of (percutaneous) revascularisation and at the level of antithrombotic treatment. Numerous trials have led to significant advancements in the development of effective anticoagulant and antiplatelet drugs. The large number of randomised controlled clinical trials (RCTs) and the huge number of patients enrolled in these RCTs, with mega trials including >10,000 patients, is unique in the history of medical research and also reflects the exceptional efforts associated with these huge research activities. The crucial issue, however, with respect to optimising treatment, relates to finding the delicate balance between the reduction of thrombotic events by effective drug treatment and the induction of bleeding that is linked to the use of potent or multiple antithrombotic agents. Interestingly, there is a gap in modern days between current guideline recommendations favouring potent platelet inhibition in ACS and the utilization of the respective drugs in clinical practice. In this review, we will summarise and discuss the past, present and future antithrombotic treatment for ACS patients with a focus on the development of optimised antiplatelet treatment strategies and their utilisation in the real world.

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Section: The Futurementioning

confidence: 99%

Antithrombotic therapy for acute coronary syndrome: Past, present and future

Sibbing

Angiolillo²,

Huber³

2017

Thromb Haemost

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“…Notwithstanding these observations, recent trials assessing patients with an indication for full-dose oral anticoagulation undergoing percutaneous coronary intervention (PCI), where triple antithrombotic therapy (aspirin plus clopidogrel together with standard doses of oral anticoagulants) has been the standard of care, have suggested that withholding aspirin has not caused a significant increase in ischaemic events and showed a lower risk of major bleeding events. 13,14 Recent in-vivo thrombosis and bleeding studies have assessed rivaroxaban in combination with P2Y12 inhibitors and found this combination to have similar efficacy as DAPT, but with a lower risk of bleeding. 15,16 These findings suggest that the role of a dual pathway antithrombotic strategy using an oral anticoagulant (in place of aspirin) with a P2Y12 inhibitor warrants additional exploration in the post-acute coronary syndromes setting.…”

Section: Introductionmentioning

confidence: 99%

“…13 Recent results from the PIONEER AF-PCI trial 14 provide further evidence that in patients with an indication for oral anticoagulation who have undergone PCI, removing aspirin seems to result in less bleeding with a reduction in the standard dose of an oral anticoagulant used for atrial fibrillation (in this case, rivaroxaban 15 mg daily) compared with triple therapy. 14 Collectively, these findings suggest that the excessive risk of bleeding seen with triple antithrombotic therapy in the post-acute coronary syndromes and post-PCI settings seems to be strongly affected by aspirin, as well as by the dose of the oral anticoagulant used.…”

mentioning

confidence: 99%

Clinically significant bleeding with low-dose rivaroxaban versus aspirin, in addition to P2Y12 inhibition, in acute coronary syndromes (GEMINI-ACS-1): a double-blind, multicentre, randomised trial

et al. 2017

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SummaryBackground Dual antiplatelet therapy (DAPT), aspirin plus a P2Y12 inhibitor, is the standard antithrombotic treatment following acute coronary syndromes. The factor Xa inhibitor rivaroxaban reduced mortality and ischaemic events when added to DAPT, but caused increased bleeding. The safety of a dual pathway antithrombotic therapy approach combining low-dose rivaroxaban (in place of aspirin) with a P2Y12 inhibitor has not been assesssed in acute coronary syndromes. We aimed to assess rivaroxaban 2·5 mg twice daily versus aspirin 100 mg daily, in addition to clopidogrel or ticagrelor (chosen at investigator discretion before randomisation), for patients with acute coronary syndromes started within 10 days after presentation and continued for 6-12 months.

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“…The outcome of the study by Gibson et al [2016] (1) entitled "Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI" suggests titrating either low-dose rivaroxaban plus P2Y12 inhibitor or very lowdose rivaroxaban plus dual antiplatelet therapy (DAPT) "blood thinning" regimen may result in bleeding reduction among individuals with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) and coronary artery stenting (CAST) compared with the standard regimen. Accomplishing an optimal anticoagulation therapy (ACT) in AF patients who have received stents requires meticulous planning and careful calculation of accurate titer values of the anticoagulant components.…”

Section: --Anonymousmentioning

confidence: 99%

“…In Gibson et al [2016], the researchers randomized 2124 non-valvular AF patients who had undergone CAST to receive, in a 1:1:1 ratio, low-dose rivaroxaban (15 mg once daily) plus a P2Y12 inhibitor for 12 months (group 1), very-low-dose rivaroxaban (2.5 mg twice daily) plus DAPT for 1, 6, or 12 months (group 2), or standard therapy with a dose adjusted VKA (once daily) plus DAPT for 1, 6, or 12 months (group 3). Note that the course and the P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) type were the basis of the stratification.…”

Section: --Anonymousmentioning

confidence: 99%