Long-term outcomes of various antithrombotic strategies in patients with acute coronary syndrome and coexisting indications for anticoagulation

Abstract

Purpose: Dual antiplatelet therapy (DAPT) is indicated for patients with acute coronary syndrome (ACS). Many ACS patients have coexistent conditions (e.g, atrial fibrillation [AF] or venous thromboembolism [VTE]) that merit anticoagulation (AC). The increased risk of major bleeding (MB), if both DAPT and AC are combined, results in physician reticence to prescribe all three drugs. Little is known about the long-term outcome of various antithrombotic therapy (AT) strategies in these complex patients. Here we report the 2 year clinical outcomes of ACS patients discharged with coexisting indications for AT. Methods: ACS patients (N=1,073) with coexisting AF or VTE from 2004–2009 were identified. Clinical variables and discharge AT (single antiplatelet therapy [SAPT] ± AC, DAPT ± AC, or AC only) were collected. Two year outcomes of net adverse cardiovascular events (NACE), including death, myocardial infarction (MI), stroke, and MB were compared according to AT strategy. Predictors of NACE were determined using multivariable logistic regression analyses. Results: The most common AT strategy used was DAPT and only 31.9% received AC therapy. Incidence of NACE for the AT strategies is shown in the table. The strongest predictors of NACE are prior stroke (hazard ratio [HR] =2.40, p=0.004), heart failure (HR = 2.15; p<0.001), Intermountain Risk Score (HR=1.89, p=0.003), multi-vessel disease (HR=1.86, p=0.039), diabetes (HR=1.49, p=0.046) and chronic obstructive lung disease (HR=1.67, p=0.035). After adjustment, AT strategy did not predict 2 year NACE. View this table: Conclusions: Among patients with ACS + AF or VTE, the most important predictors of 2 year NACE did not include AT strategy. Although risk of MB was affected by AT strategy, its incidence was low. These findings suggest that physicians are making appropriate AT choices based on each individual patient's overall risk.