Abstract
BackgroundPatients on oral anticoagulants (OACs) undergoing percutaneous coronary intervention (PCI) also require aspirin and a P2Y12 inhibitor (triple therapy). However, triple therapy increases bleeding. The use of non-vitamin K antagonist oral anticoagulants (NOACs) and stronger P2Y12 inhibitors has increased. The aim of our study was to gain insight into antithrombotic management over time.MethodsA prospective cohort study of patients on OACs for atrial fibrillation or a mechanical heart valve undergoing PCI was performed. Thrombotic outcomes were myocardial infarction, stroke, target-vessel revascularisation and all-cause mortality. Bleeding outcome was any bleeding. We report the 30-day outcome.ResultsThe mean age of the 758 patients was 73.5 ± 8.2 years. The CHA2DS2-VASc score was ≥ 3 in 82% and the HAS-BLED score ≥ 3 in 44%. At discharge, 47% were on vitamin K antagonists (VKAs), 52% on NOACs, 43% on triple therapy and 54% on dual therapy. Treatment with a NOAC plus clopidogrel increased from 14% in 2014 to 67% in 2019. The rate of thrombotic (4.5% vs 2.0%, p = 0.06) and bleeding (17% vs. 14%, p = 0.42) events was not significantly different in patients on VKAs versus NOACs. Also, the rate of thrombotic (2.9% vs 3.4%, p = 0.83) and bleeding (18% vs 14%, p = 0.26) events did not differ significantly between patients on triple versus dual therapy.ConclusionsPatients on combined oral anticoagulation and antiplatelet therapy undergoing PCI are elderly and have both a high bleeding and ischaemic risk. Over time, a NOAC plus clopidogrel became the preferred treatment. The rate of thrombotic and bleeding events was not significantly different between patients on triple or dual therapy or between those on VKAs versus NOACs.Supplementary InformationThe online version of this article (10.1007/s12471-022-01664-0) contains supplementary material, which is available to authorized users.
Highlights
Chronic oral anticoagulant (OAC) therapy is recommended in patients with atrial fibrillation (AF) and a CHA2DS2-VASc score of ≥ 1 for men and ≥ 2 for woman [1], as well as for patients with a mechanical heart valve
After correction for the year of the procedure, we found that the strongest predictors for vitamin K antagonists (VKAs) prescription were prior myocardial infarction, coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), congestive heart failure, peripheral artery disease and ST-elevation myocardial infarction (STEMI) at presentation (Electronic Supplementary Material, Table S1a)
Bleeding rates were similar in patients on non-vitamin K antagonist oral anticoagulants (NOACs) and those on VKAs (17% vs 14%, p = 0.42), after excluding patients not eligible for NOACs
Summary
Chronic oral anticoagulant (OAC) therapy (class I) is recommended in patients with atrial fibrillation (AF) and a CHA2DS2-VASc score of ≥ 1 for men and ≥ 2 for woman [1], as well as for patients with a mechanical heart valve When these patients undergo percutaneous coronary intervention (PCI) with stenting or suffer from acute coronary syndrome (ACS), dual antiplatelet treatment (DAPT) with aspirin and a P2Y12 inhibitor, such as clopidogrel, ticagrelor or prasugrel, is indicated [2–4]. This so-called triple therapy (an OAC combined with DAPT) aims to minimise the risk of stroke and coronary ischaemic events [5].
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