Outcomes in patients with atrial fibrillation undergoing coronary artery stenting with a low-moderate CHA2DS2VASc score: do they need anticoagulation?

Abstract

Background: European Society of Cardiology guidelines for the management of atrial fibrillation (AF) recommend oral anticoagulation (OAC) in patients with CHA2DS2VASc score ≥1. However, these recommendations are not always followed in clinical practice. We assessed the impact of OAC in the particular group of patients with AF, and a low-moderate thromboembolic risk submitted to PCI with stenting (PCI-S), and therefore have an indication for dual antiplatelet therapy (DAPT). Methods: A multicenter study was conducted from 2007 to 2011 to identify patients with non-valvular AF and low-moderate thromboembolism risk (CHA2DS2VASc <2) who had undergone PCI-S. We analyzed the ocurrence of major bleeding, thromboembolism, mortality, acute myocardial infarction, target revascularization, the composite of major adverse cardiac events (ie, death, acute myocardial infarction, and/or target lesion revascularization), and the composite of major adverse events (ie, major adverse cardiac events, major bleeding, or thromboembolism) during the first year after PCI-S. Results: We identified 640 consecutive patients with AF (75.2% male, 73.2±8.2 years). 170 (27%) of them had a CHA2DS2VASc 3 (7.6% vs 4.2%, p=0.29). At follow-up, patients on OAC showed a higher mortality (1.3% vs 8.4%, p=0.03) due an excess of cardiovascular death (0% vs 8.4%, p=0.008), and a higher rate of major bleeding (0% versus 5.3%; P=0.05). However, they showed a similar rates of thromboembolism (1.3% vs 1.1%, p=0.68), major adverse cardiac events (9.3% versus 13.7%; P=0.26) and major adverse events (18.7% versus 26.3%; P=0.16) compared to patients without OAC. A total of 9 patients (5.3%) died during follow-up; 8 (88.9%) of them were on OAC, 4 patients had had a bleeding event, and 3 of them had a CHA2DS2VASc=1. In a multivariate analysis, in patients with CHA2DS2VASc < 2, the use of OAC showed a trend towards increased mortality (OR 8.4 95% CI 0.91 to 77.6, p=0.05), and was a predictor of major bleeding (OR 2.9: 1.04-8.25, p=0.042). Conclusions: In patients with AF and CHA2DS2VASc <2 undergoing PCI-S, the addition of OAC to DAPT increases cardiovascular mortality as well as major bleeding, and does not provide any apparent benefit preventing thromboembolic events.