Abstract
BackgroundA combination of warfarin, aspirin and clopidogrel is indicated after percutaneous coronary intervention (PCI) in some patients, despite the higher risk of bleeding inferred by this triple therapy.ObjectivesWhether the treatment quality of warfarin measured by iTTR (individual time within therapeutic INR range) is associated with bleeding complications during triple therapy after PCI.MethodsA retrospective register study consisting of 601 triple treated PCI patients from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). The cohort was cross-matched with the Swedish Patient Registry for background characteristics and bleeding complications up to 6 months after PCI using ICD10 codes, the Prescribed Drug Registry for ongoing medications, and the national oral anticoagulation registry Auricula for warfarin treatment quality. The patients were grouped into four iTTR groups: <50%, 50–69.9%, 70–84.9% and >85% as well as iTTR above or below 70%.ResultsOf 601 patients, 39 (6.5%) had a bleeding complication (type 2 according to BARC). Bleeding was more common for iTTR<70% compared to iTTR>70%, 28 (9.3%) vs. 11 (3.7%) (p = 0.005). The bleeding frequency increased gradually from the best group, iTTR>85% with four bleeders (3.3%) up to 17 bleeders (13.3%) in the worst group with iTTR<50% (p = 0.003), with a corresponding bleeding rate per 100 treatment years of 8.0 and 44.9, respectively. In multivariate analysis low BMI, HR 1.11 (95% CI 1.01–1.22), a medical history of anemia HR 3.17 (1.16–8.69) and iTTR < 70% HR 2.86 (1.25–6.53) increased the risk of bleeding.ConclusionTriple therapy after PCI confers a high risk of bleeding events. Warfarin treatment quality measured by iTTR as well as a medical history of anemia are strong independent predictors of bleeding in these patients. Physicians should pay more attention to iTTR after PCI.
Highlights
AnticoagulationThe vitamin K antagonist, warfarin, is the only oral anticoagulant that is approved for all common indications to anticoagulation and is the anticoagulant still most commonly used in combination with antiplatelet therapy after percutaneous coronary intervention (PCI).Triple therapy after PCITo reduce the risk of stent thrombosis and thereby myocardial infarction and death, double platelet inhibition is the recommended treatment after PCI
Bleeding was more common for in Therapeutic Range" (iTTR)70%, 28 (9.3%) vs. 11 (3.7%) (p = 0.005)
Triple therapy after PCI confers a high risk of bleeding events
Summary
AnticoagulationThe vitamin K antagonist, warfarin, is the only oral anticoagulant that is approved for all common indications to anticoagulation (atrial fibrillation, recent or repeated pulmonary embolism, cardiac embolism and mechanical heart valve prosthesis) and is the anticoagulant still most commonly used in combination with antiplatelet therapy after PCI.Triple therapy after PCITo reduce the risk of stent thrombosis and thereby myocardial infarction and death, double platelet inhibition (aspirin and ADP receptor antagonists such as clopidogrel, prasugrel or ticagrelor) is the recommended treatment after PCI. The vitamin K antagonist, warfarin, is the only oral anticoagulant that is approved for all common indications to anticoagulation (atrial fibrillation, recent or repeated pulmonary embolism, cardiac embolism and mechanical heart valve prosthesis) and is the anticoagulant still most commonly used in combination with antiplatelet therapy after PCI. Atrial fibrillation or some other indication for anticoagulation therapy is not uncommon among patients with coronary heart disease and thereby combinations of antithrombotic treatments occurs [1,2,3]. Previous studies have shown a significantly increased risk of bleeding if patients take three drugs simultaneously (warfarin, aspirin and clopidogrel), so-called "triple therapy" [3,4,5,6]. A combination of warfarin, aspirin and clopidogrel is indicated after percutaneous coronary intervention (PCI) in some patients, despite the higher risk of bleeding inferred by this triple therapy.
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