Abstract 19218: Are the Guidelines Recommendations Followed in the Clinical Practice in Patients With Atrial Fibrillation Undergoing Coronary Stenting?

Abstract

Background: Patients with atrial fibrillation (AF) undergoing coronary stenting (CS) have an increased risk of bleeding due to the combination of dual antiplatelet therapy (DAPT: aspirin and clopidogrel) with anticoagulation (TT:triple therapy). The use of TT is a class IIb recommendation of the ACC/AHA/ESC guidelines. Other recommendations such as the use of drug eluting stent(DES), radial approach and closure devices in femoral access are preferred. Objective:to assess adherence in clinical practice to triple therapy, vascular access, the use of closure devices and the type of stent implanted. Methods: a multicenter study from 2007 to 2011 identified patients with non-valvular AF submitted to CS. In the included patients the risk associated to TT in terms of use and duration of TT, vascular access, and DES were assessed. Results: We identified 640 consecutive patients with AF, 320 (50%) of them were ≥75 years. Among them, 224 (35.2%) had CHADS2 score > 2, 46(73%) CHA2DS2VASc>2, and 164 (25.6%) had a high bleeding risk (HASBLED>3). In 328 (51.3%) a radial approach was chosen.At discharge, 321 (50.2%) patients received TT, 44(6.9%) warfarin plus clopidogrel and 275(41.3%) DAPT. During follow-up, 63 patients(9.8%) died for any cause, and 46(7.2%) because of a cardiovascular cause. 116(18.1%) had a bleeding event, and 37(5.8%) of them were major bleedings. A major adverse cardiac event(MACE: death, acute myocardial infarction and/or target vessel failure) occurred in 111(17.3%) patients and major adverse event (MAE: MACE and/or major bleeding) in 190(29.7%). A multivariate analysis identified as predictors of cardiovascular mortality the age(OR: 1.05; 95%CI 1.00 to 1.11, p=0.043), renal failure(OR 6.24; 95% CI 2.77 to 14.06, p=0.01), and the use of warfarin plus clopidogrel(OR 4.62; 95%CI 1.68 to 12.7, p=0.03).The use of DES, used arterial approach or the use of closure device were not predictors. Conclusions: In patients with non-valvular AF submitted to CS guidelines recommendations are not always followed in clinical practice. In these patients, the use of warfarin plus clopidogrel is associated to a higher cardiovascular mortality, while other recommendations such as the use of DES, arterial access approach or closure devices did not seem have effect.