Triple therapy in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention/stenting

Kozieł, Monika; Potpara, Tatjana; Lip, Gregory Y.H.

doi:10.1002/rth2.12319

Cited by 4 publications

(4 citation statements)

References 66 publications

(103 reference statements)

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“…Its uses predate COVID-19, where it is successfully prescribed in patients where thromboses (which may or may not involve fibrinaloid clots) are particularly worrisome and in various coronary diseases accompanied by atrial fibrillation. Here strong anticoagulant treatments tailored to the needs of the individual patient are recommended [ 270 ], commonly involving dual or triple treatments with various anticoagulant agents. The present authors have focused on the ‘triple treatment’ for anticoagulation that involves an oral anticoagulant plus two drugs designed to decrease platelet activation (usually the P2Y 12 inhibitor clopidogrel, plus low-dose aspirin).…”

Section: Consequences For Treatment Protocolsmentioning

confidence: 99%

A central role for amyloid fibrin microclots in long COVID/PASC: origins and therapeutic implications

Kell

Laubscher

Pretorius

2022

Biochemical Journal

200

256

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Post-acute sequelae of COVID (PASC), usually referred to as ‘Long COVID’ (a phenotype of COVID-19), is a relatively frequent consequence of SARS-CoV-2 infection, in which symptoms such as breathlessness, fatigue, ‘brain fog’, tissue damage, inflammation, and coagulopathies (dysfunctions of the blood coagulation system) persist long after the initial infection. It bears similarities to other post-viral syndromes, and to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Many regulatory health bodies still do not recognize this syndrome as a separate disease entity, and refer to it under the broad terminology of ‘COVID’, although its demographics are quite different from those of acute COVID-19. A few years ago, we discovered that fibrinogen in blood can clot into an anomalous ‘amyloid’ form of fibrin that (like other β-rich amyloids and prions) is relatively resistant to proteolysis (fibrinolysis). The result, as is strongly manifested in platelet-poor plasma (PPP) of individuals with Long COVID, is extensive fibrin amyloid microclots that can persist, can entrap other proteins, and that may lead to the production of various autoantibodies. These microclots are more-or-less easily measured in PPP with the stain thioflavin T and a simple fluorescence microscope. Although the symptoms of Long COVID are multifarious, we here argue that the ability of these fibrin amyloid microclots (fibrinaloids) to block up capillaries, and thus to limit the passage of red blood cells and hence O2 exchange, can actually underpin the majority of these symptoms. Consistent with this, in a preliminary report, it has been shown that suitable and closely monitored ‘triple’ anticoagulant therapy that leads to the removal of the microclots also removes the other symptoms. Fibrin amyloid microclots represent a novel and potentially important target for both the understanding and treatment of Long COVID and related disorders.

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Section: Consequences For Treatment Protocolsmentioning

confidence: 99%

A central role for amyloid fibrin microclots in long COVID/PASC: origins and therapeutic implications

Kell

Laubscher

Pretorius

2022

Biochemical Journal

200

256

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“…Clinical management of AF and ACS, although different, includes antithrombotic therapy to prevent increased risk of stroke and further cardiac events [1,4,12]. Oral anticoagulants (OACs), which can either be vitamin K antagonists (VKAs; e.g., warfarin) or novel oral anticoagulants (NOACs; e.g., apixaban, dabigatran, edoxaban, rivaroxaban), are used for AF treatment, whereas dual antiplatelet therapy (DAPT) consisting of aspirin and P2Y12 inhibitors (e.g., clopidogrel) is used for ACS treatment [1,4,12,13]. The optimal antithrombotic regimen for patients with AF having ACS/PCI remains a clinical conundrum due to an increased risk of major and fatal bleedings associated with a combination of OAC and DAPT (i.e., triple therapy) [1,4,12,13].…”

Section: Introductionmentioning

confidence: 99%

“…Oral anticoagulants (OACs), which can either be vitamin K antagonists (VKAs; e.g., warfarin) or novel oral anticoagulants (NOACs; e.g., apixaban, dabigatran, edoxaban, rivaroxaban), are used for AF treatment, whereas dual antiplatelet therapy (DAPT) consisting of aspirin and P2Y12 inhibitors (e.g., clopidogrel) is used for ACS treatment [1,4,12,13]. The optimal antithrombotic regimen for patients with AF having ACS/PCI remains a clinical conundrum due to an increased risk of major and fatal bleedings associated with a combination of OAC and DAPT (i.e., triple therapy) [1,4,12,13]. Moreover, there is limited guidance on the optimal strategy and lack of evidence for all possible combinations of novel antiplatelet and anticoagulant agents.…”

Section: Introductionmentioning

confidence: 99%

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Cost-effectiveness analysis of apixaban versus vitamin K antagonists for antithrombotic therapy in patients with atrial fibrillation after acute coronary syndrome or percutaneous coronary intervention in Spain

Rivolo¹,

Fusco

Polanco³

et al. 2021

PLoS ONE

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Background/Objective AUGUSTUS trial demonstrated that, for patients with atrial fibrillation (AF) having acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), an antithrombotic regimen with apixaban and P2Y12 resulted in less bleeding, fewer hospitalizations, and similar ischemic events than regimens including a vitamin K antagonist (VKA), aspirin, or both. This study objective was to evaluate long-term health and economic outcomes and the cost-effectiveness of apixaban over VKA, as a treatment option for patients with AF having ACS/PCI. Methods A lifetime Markov cohort model was developed comparing apixaban versus VKA across multiple treatment strategies (triple [with P2Y12 + aspirin] or dual [with P2Y12] therapy followed by monotherapy [apixaban or VKA]; triple followed by dual and then monotherapy; dual followed by monotherapy). The model adopted the Spanish healthcare perspective, with a 3-month cycle length and costs and health outcomes discounted at 3%. Results Treatment with apixaban resulted in total cost savings of €883 and higher life years (LYs) and quality-adjusted LYs (QALYs) per patient than VKA (net difference, LYs: 0.13; QALYs: 0.11). Bleeding and ischemic events (per 100 patients) were lower with apixaban than VKA (net difference, –13.9 and –1.8, respectively). Incremental net monetary benefit for apixaban was €3,041, using a willingness-to-pay threshold of €20,000 per QALY. In probabilistic sensitivity analysis, apixaban was dominant in the majority of simulations (92.6%), providing additional QALYs at lower costs than VKA. Conclusions Apixaban was a dominant treatment strategy than VKA from both the Spanish payer’s and societal perspectives, regardless of treatment strategy considered.

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Impact of new-onset atrial fibrillation in patients with ST-segment elevation myocardial infarction

Minder,

Mannhart,

Brunner

et al. 2024

J Interv Card Electrophysiol

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Background New-onset atrial fibrillation (NOAF) complicating ST-segment elevation myocardial infarction (STEMI) remains clinically challenging. The aim of this study was to assess the incidence of NOAF, identify risk factors for the development of atrial fibrillation (AF), and analyze the impact on patient care, therapy, and outcomes during long-term follow-up. Methods This retrospective single-center study reviewed consecutive patients undergoing coronary angiography (CAG) for acute STEMI between May 2015 and September 2023. Patients were stratified in NOAF, defined as AF diagnosed during the index hospitalization or within 12 months of follow-up, AF prior to the hospitalization for STEMI, and patients with no AF. Results We analyzed 1301 consecutive patients undergoing CAG for STEMI. NOAF was detected in 112 patients (9.8%), and 68 patients (5.2%) had prior AF. NOAF patients were 74% males, with a mean age of 69 ± 11 years. During a median follow-up of 683 days, the rates of stroke were 10% in patients with NOAF compared to 3.8% (p = 0.001) in patients without AF. Major bleeding occurred in 7% vs. 1.7%, p = 0.001, and death in 16% vs. 6.8%, p < 0.001 of patients with NOAF vs. no AF. Conclusion NOAF was detected in almost 1 out of 10 STEMI patients and was associated with a higher rate of stroke, major bleeding, and death as in patients with no AF and with similar rates compared with prior AF. Future studies assessing optimal anticoagulation therapy in this challenging patient population are warranted. Graphical abstract Central illustration: New-onset atrial fibrillation in patients with ST-segment elevation myocardial infarction: Inclusion criteria, stratification, and outcome data of AF and no AF patients in ST-segment elevation myocardial infarction. AF atrial fibrillation, NOAF new-onset atrial fibrillation

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Triple therapy in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention/stenting

Cited by 4 publications

References 66 publications

A central role for amyloid fibrin microclots in long COVID/PASC: origins and therapeutic implications

A central role for amyloid fibrin microclots in long COVID/PASC: origins and therapeutic implications

Cost-effectiveness analysis of apixaban versus vitamin K antagonists for antithrombotic therapy in patients with atrial fibrillation after acute coronary syndrome or percutaneous coronary intervention in Spain

Impact of new-onset atrial fibrillation in patients with ST-segment elevation myocardial infarction

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