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Thromb Haemost 2013; 110(03): 560-568
DOI: 10.1160/TH13-04-0351
Blood Coagulation, Fibrinolysis and Cellular Haemostasis
Schattauer GmbH

Anticoagulation in patients with atrial fibrillation undergoing coronary stent implantation

Anne Bernard
1   Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
,
Laurent Fauchier
1   Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
,
Céline Pellegrin
1   Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
,
Nicolas Clementy
1   Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
,
Christophe Saint Etienne
1   Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
,
Amitava Banerjee
2   University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
,
Djedjiga Naudin
1   Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
,
Denis Angoulvant
1   Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France
› Author Affiliations
Further Information

Publication History

Received: 29 April 2013

Accepted after major revision: 26 June 2013

Publication Date:
22 November 2017 (online)

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Summary

In patients with atrial fibrillation (AF) undergoing coronary stent implantation, the optimal antithrombotic strategy is unclear. We evaluated whether use of oral anticoagulation (OAC) was associated with any benefit in morbidity or mortality in patients with AF, high risk of thromboembolism (TE) (CHA2DS2-VASC score ≥2) and coronary stent implantation. Among 8,962 unselected patients with AF seen between 2000 and 2010, a total of 2,709 (30%) had coronary artery disease and 417/2,709 (15%) underwent stent implantation while having CHA2DS2-VASC score ≥2. During follow-up (median=650 days), all TE, bleeding episodes, and major adverse cardiac events (i.e. death, acute myocardial infarction, target lesion revascularisation) were recorded. At discharge, 97/417 patients (23%) received OAC, which was more likely to be prescribed in patients with permanent AF and in those treated for elective stent implantation. The incidence of outcome event rates was not significantly different in patients treated and those not treated with OAC. However, in multivariate analysis, the lack of OAC at discharge was independently associated with increased risk of death/stroke/systemic TE (relative risk [RR] =2.18, 95% confidence interval [CI] 1.02-4.67, p=0.04), with older age (RR =1.12, 1.04-1.20, p=0.003), heart failure (RR =3.26, 1.18-9.01, p=0.02), and history of stroke (RR =18.87, 3.11-111.11, p=0.001). In conclusion, in patients with AF and high thromboembolic risk after stent implantation, use of OAC was independently associated with decreased risk of subsequent death/stroke/systemic TE, suggesting that OAC should be systematically used in this patient population.

Keywords

Atrial fibrillation - oral anticoagulant - antiplatelet agent - coronary stent implantation
 

  • References

  • 1 Camm AJ, Kirchhof P, Lip GY. et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology. Eur Heart J 2010; 31: 2369-2429.
    CrossrefPubMedGoogle Scholar
  • 2 You JJ, Singer DE, Howard PA. et al. Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis. 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e531S-e575S.
    CrossrefPubMedGoogle Scholar
  • 3 Nabauer M, Gerth A, Limbourg T. et al. The Registry of the German Competence NETwork on Atrial Fibrillation: patient characteristics and initial management. Europace 2009; 11: 423-434.
    CrossrefPubMedGoogle Scholar
  • 4 Nieuwlaat R, Capucci A, Camm AJ. et al. Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation. Eur Heart J 2005; 26: 2422-2434.
    CrossrefPubMedGoogle Scholar
  • 5 Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI). Wijns W, Kolh P, Danchin N. et al. Guidelines on myocardial revascularization. Eur Heart J 2010; 31: 2501-2555.
    CrossrefPubMedGoogle Scholar
  • 6 Lip GY, Nieuwlaat R, Pisters R. et al. Refining clinical risk stratification for predicting stroke and thrombo-embolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest 2010; 137: 263-272.
    CrossrefPubMedGoogle Scholar
  • 7 Pisters R, Lane DA, Nieuwlaat R. et al. A novel user- friendly score (HAS-BLED) to assess one-year risk of major bleeding in atrial fibrillation patients: The Euro Heart Survey. Chest 2010; 138: 1093-1100.
    CrossrefPubMedGoogle Scholar
  • 8 Cutlip DE, Windecker S, Mehran R. et al. Academic Research Consortium. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 2007; 115: 2344-2351.
    CrossrefPubMedGoogle Scholar
  • 9 Fosbol EL, Wang TY, Li S. et al. Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction. Am Heart J 2012; 163: 720-728.
    CrossrefPubMedGoogle Scholar
  • 10 Ruiz-Nodar JM, Marín F, Hurtado JA. et al. Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation. J Am Coll Cardiol 2008; 51: 818-825.
    CrossrefPubMedGoogle Scholar
  • 11 Ruiz-Nodar JM, Marín F, Roldán V. et al. Should We Recommend Oral Anticoagulation Therapy in Patients With Atrial Fibrillation Undergoing Coronary Artery Stenting With a High HAS-BLED Bleeding Risk Score?. Circ Cardiovasc Interv 2012; 05: 459-466.
    CrossrefPubMedGoogle Scholar
  • 12 Rubboli A, Halperin JL, Airaksinen KE. et al. Antithrombotic therapy in patients treated with oral anticoagulation undergoing coronary artery stenting. An expert consensus document with focus on atrial fibrillation. Ann Med 2008; 40: 428-436.
    CrossrefPubMedGoogle Scholar
  • 13 Connolly SJ, Pogue J, Hart RG. et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med 2009; 360: 2066-2078.
    CrossrefPubMedGoogle Scholar
  • 14 ACTIVE Writing Group of the ACTIVE Investigators. Connolly S, Pogue J, Hart R. et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W). Lancet 2006; 367: 1903-1912.
    CrossrefPubMedGoogle Scholar
  • 15 Leon MB, Baim DS, Popma JJ. et al. A clinical trial comparing three antithrombotic drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med 1998; 339: 1665-1671.
    CrossrefPubMedGoogle Scholar
  • 16 Andreotti F, Testa L, Biondi-Zoccai GG. et al. Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25,307 patients. Eur Heart J 2006; 27: 519-526.
    CrossrefPubMedGoogle Scholar
  • 17 Karjalainen PP, Porela P, Ylitalo A. et al. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J 2007; 28: 726-732.
    CrossrefPubMedGoogle Scholar
  • 18 Khurram Z, Chou E, Minutello R. et al. Combination therapy with aspirin, clopidogrel and warfarin following coronary stenting is associated with a significant risk of bleeding. J Invasive Cardiol 2006; 18: 162-164.
    PubMedGoogle Scholar
  • 19 Lamberts M, Olesen JB, Ruwald MH. et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study. Circulation 2012; 126: 1185-1193.
    CrossrefPubMedGoogle Scholar
  • 20 Stenestrand U, Lindbäck J, Wallentin L. Anticoagulation therapy in atrial fibrillation in combination with acute myocardial infarction influences long-term outcome: a prospective cohort study from the Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA). Circulation 2005; 112: 3225-3231.
    CrossrefPubMedGoogle Scholar
  • 21 Fauchier L, Pellegrin C, Bernard A. et al. Comparison of frequency of major adverse events in patients with atrial fibrillation receiving bare-metal versus drug-eluting stents in their coronary arteries. Am J Cardiol 2012; 110: 7-12.
    CrossrefPubMedGoogle Scholar
  • 22 Rubboli A, Kovacic J.C., Mehran R. et al. Coronary stent implantation in patients committed to long-term oral anticoagulation therapy: successfully navigating the treatment options. Chest 2011; 139: 981-987.
    CrossrefPubMedGoogle Scholar
  • 23 Zhao HJ, Zheng ZT, Wang ZH. et al. "Triple therapy" rather than "triple threat": a meta-analysis of the two antithrombotic regimens after stent implantation in patients receiving long-term oral anticoagulant treatment. Chest 2011; 139: 260-270.
    CrossrefPubMedGoogle Scholar
  • 24 Gao F, Zhou YJ, Wang ZJ. et al. Comparison of different antithrombotic regimens for patients with atrial fibrillation undergoing drug-eluting stent implantation. Circ J 2010; 74: 701-708.
    CrossrefPubMedGoogle Scholar
  • 25 Lip GY, Huber K, Andreotti F. et al European Society of Cardiology Working Group on Thrombosis. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting. Thromb Haemost 2010; 103: 13-28.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Faxon DP, Eikelboom JW, Berger PB. et al. Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective. Thromb Haemost 2011; 106: 572-584.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Huber K, Airaksinen KJ, Cuisset T. et al. Antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting: similarities and dissimilarities between North America and Europe. Thromb Haemost 2011; 106: 569-571.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Dewilde WJ, Oirbans T, Verheugt FW. et al WOEST study investigators. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381: 1107-1115.
    CrossrefPubMedGoogle Scholar
  • 29 Wiviott SD, Braunwald E, McCabe CH. et al TRITON-TIMI 38 Investigators. Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. Lancet 2008; 371: 1353-1363.
    CrossrefPubMedGoogle Scholar
  • 30 Bhala N, Taggar JS, Rajasekhar P, Banerjee A. Anticipating and managing bleeding complications in patients with coronary stents who are receiving dual antiplatelet treatment. Br Med J 2011; 343: d4264.
    CrossrefPubMedGoogle Scholar
  • 31 Connolly SJ, Ezekowitz MD, Yusuf S. et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-1151.
    CrossrefPubMedGoogle Scholar
  • 32 Granger CB, Alexander JH, McMurray JJ. et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2011; 365: 981-992.
    CrossrefPubMedGoogle Scholar
  • 33 Cairns JA, Connolly S, McMurtry S. et al CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thrombo-embolism in atrial fibrillation and flutter. Can J Cardiol 2011; 27: 74-90.
    CrossrefPubMedGoogle Scholar
  • 34 Connolly SJ, Eikelboom J, Joyner C. et al. Apixaban in patients with atrial fibrillation. N Engl J Med 2011; 364: 806-817.
    CrossrefPubMedGoogle Scholar