Double Antithrombotic Therapy Research Articles

Simulated Impact of Double Antithrombotic Therapy in White and Non-White Patients With Stable Peripheral, Cerebrovascular and/or Coronary Artery Disease

Simulated Impact of Double Antithrombotic Therapy in White and Non-White Patients With Stable Peripheral, Cerebrovascular and/or Coronary Artery Disease

Research progress of double antithrombotic therapy in cardiovascular diseases

Research progress of double antithrombotic therapy in cardiovascular diseases

P135 A CASE OF RIGHT CORONARY ARTERY ANEURYSM COMPLICATED BY ENDOVASCULAR THROMBOSIS

Abstract Coronary artery aneurysm is a rare disorder with prevalence in male population. The most commonly involved vessel is the right coronary artery followed by the anterior descending artery. The most frequent etiologies are coronary atherosclerosis and Kawasaki disease. The treatment of coronary aneurysms with significant stenosis is often surgical, with implantation of covered stents in case of saccular aneurysms. In coronary artery aneurysms without significant stenosis, medical therapy is often the most suitable choice. Case report We present a case of a 68–year–old man with history of hypertension and dyslipidemia, who arrived to our ED with inferior STEMI. Left coronary angiography showed a 75% stenosis of the distal anterior descending artery and subocclusion of the first left marginal artery. Right coronary angiography revealed a severely ectatic vessel (7–8 mm diameter) with intraluminal thrombosis and markedly slowed flow (TIMI 1). Considering the regression of symptoms and ECG alterations, intracoronary bolus of Tirofiban was performed followed by i.v. infusion of 24 hours in association with DAPT. Blood tests did not detect any relevant alterations of coagulation profile but only an heterozygous mutation for MTHFR with slightly altered homocysteine values. Six days later, a second coronary angiography was performed which confirmed the persistence of thrombotic formation into the right coronary artery that was treated with rheolytic thromboaspiration and TIMI 2 final flow. In consideration of the angiographic findings, it was decided not to implant coronary stents. After multidisciplinary team discussion it was decided to associate DAPT with oral anticoagulant therapy (Warfarin 5 mg, INR 2–3) The patient was discharged with indication to continue the triple antithrombotic therapy for 6 months followed by double antithrombotic therapy with ASA and Warfarin. Conclusions Coronary aneurysms in the context of ACS are rare findings, often caused by endovascular thrombosis. Thrombolytic therapy, rheolytic thromboaspiration and anticoagulation therapy are valid tools for the successful treatment of such cases.

Design of the PERSEO Registry on the management of patients treated with oral anticoagulants and coronary stent.

Percutaneous coronary intervention with stent implantation (PCI-S) in patients requiring chronic oral anticoagulant therapy (OAC) is associated with an increased risk of bleeding and ischemic complications. Different randomized studies showed a significant advantage of a double antithrombotic therapy and superiority of direct oral anticoagulant (DOAC) compared with warfarin, but real-world data are limited. Aim is to evaluate the antithrombotic management and clinical outcome of patients with an indication for OAC who undergo PCI-S in a 'real-world' setting. The multicentre prospective observational PERSEO (PERcutaneouS coronary intErventions in patients treated with Oral anticoagulant therapy) Registry (ClinicalTrials.gov Identifier: NCT03392948) has been designed to enrol patients requiring OAC treated by PCI-S in 25 Italian centres. A target of at least 1080 patients will be followed for 1 year and data on thromboembolic and bleeding events and changes in antithrombotic therapy will be registered. The primary end point is a combined measure of efficacy and safety outcome (NACE), including major bleeding events and major adverse cardiac and cerebral events at 1-year follow-up in patients treated with DOAC (and dual or triple antiplatelet therapy) compared with the corresponding strategies with vitamin K antagonists. A secondary prespecified analysis has been defined to evaluate NACE in dual versus triple antithrombotic therapy after hospital discharge at 1-year follow-up. The PERSEO Registry will investigate in a 'real world' setting the safety and efficacy of DOAC versus warfarin and dual versus triple antithrombotic therapy in patients with indication for oral anticoagulant therapy who undergo PCI-S.

A novel risk score to identify the need for triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a post hoc analysis of the RE-DUAL PCI trial.

Current guidelines recommend treating atrial fibrillation (AF) patients who undergo percutaneous coronary intervention (PCI) with triple antithrombotic therapy (TAT) for up to one month in patients at high thrombotic risk. It is unclear how to select these high-risk patients. The aim of this study was to identify patients at high thrombotic risk who might benefit from TAT over double antithrombotic therapy (DAT). This study was a post hoc subanalysis of the RE-DUAL PCI trial. A Cox proportional hazards model was built by stepwise selection of plausible predictor variables for a composite ischaemic endpoint, defined as cardiovascular death, myocardial infarction (MI), stent thrombosis (ST) or ischaemic stroke. The effect of TAT versus DAT was calculated for those patients with the highest proportion of predicted thrombotic risk. A simplified risk score was constructed based on beta-coefficients. For 209 patients (7.7%) the composite ischaemic endpoint occurred during the first year. The simplified risk score contained six variables. In patients with a score ≥5 (n=154, 5.7%), a significant reduction in the composite of MI and ST was observed with TAT versus DAT (6.3% vs 21.0%, p=0.041), without a penalty in terms of bleeding. In patients at low thrombotic risk, a significant increase in bleeding was observed without a reduction of ischaemic events. Our findings support the use of DAT in the majority of patients. A small subgroup of patients might benefit from TAT and we propose a novel clinical risk score to select these patients.

РАННИЕ И ОТДАЛЕННЫЕ КЛИНИЧЕСКИЕ ИСХОДЫ У ПАЦИЕНТОВ С НЕСТАБИЛЬНОЙ СТЕНОКАРДИЕЙ И СТЕНТИРОВАНИЕМ КОРОНАРНЫХ АРТЕРИЙ

Aim. To study early and long-term clinical outcomes in patients with unstable angina (UA) and coronary artery stenting based on the results of a seven-year follow-up. Materials and Methods. The study included 165 patients with UA and coronary artery stenting. The average age of patients was 59.04±10.34 years; the number of male patients was 129 (78.2%). The risk by the GRACE scale was 96.9±17.46 points. The average number of affected coronary arteries was 2.23±1.07 per person, the average number of implanted stents was 2.10±1.45 per person, the average length of the stented area was 43.12±25.6 mm. Everolimus- or sirolimus-eluting stents were used. All patients were assessed for troponin I, myeloperoxidase, and C-reactive protein; platelet, plasma, and vascular hemostasis were evaluated. The patients underwent echocardiography, coronary angiography. The follow-up period was 7±1.6 years. Results. During a 7-year follow-up period, with endovascular treatment strategy and double antithrombotic therapy with clopidogrel 75 mg and acetylsalicylic acid 75 mg repeated UA developed in 91 (55.2%) pts and myocardial infarction was registered in 21 (12.7%) pts. Cardiovascular mortality was 7.3%. Independent stent thrombosis risk predictors included AUC ADR test ≥ 77.5 U, troponin I ≥ 0.90 ng/ml, total length of the stented area ≥ 60 mm. Independent predictors of the development of restenosis/neoatherosclerosis included: more than 4 implanted stents per patient (RR 1.440; 95% CI 1.233-1.681), the total length of the stented area ≥ 60 mm (RR 1.532; 95% CI 1.245-1.884), homocysteine ≥ 14 µmol/l (RR 1.479; 95% CI 1.168-1.876), myeloperoxidase ≥ 300 pmol/l (RR 1.351; 95% CI 1.102-1.656), with risk factors including a history of coronary heart disease for more than 5 years (RR 13.011; 95% CI 4.226-40.050), diabetes mellitus (RR 1.367; 95% CI 1.136-1.647). Conclusion. The number of early and long-term coronary events in patients with unstable angina and coronary artery stenting was estimated. Predictors of stent thrombosis, restenosis and the formation of new atherosclerotic plaques outside the stenting zone were identified.

Rotational Thromboelastometry in High-Risk Patients on Dual Antithrombotic Therapy After Percutaneous Coronary Intervention.

Aims: Patients using antithrombotic drugs after percutaneous coronary intervention (PCI) are at risk for bleeding and recurrent ischemia. We aimed to explore routine and tissue plasminogen activated (tPA) ROTEM results in a post-PCI population on dual antithrombotic treatment.Methods and Results: In this prospective cohort, 440 patients treated with double antithrombotic therapy after recent PCI and with ≥3 risk factors for either ischemic or bleeding complications were included and compared with a control group (n = 95) consisting of perioperative patients not using antithrombotic medication. Laboratory assessment, including (tPA) ROTEM, was performed one month post-PCI and bleeding/ischemic complications were collected over a five-month follow-up. Patients were stratified by antithrombotic regimen consisting of a P2Y12 inhibitor with either aspirin (dual antiplatelet therapy; DAPT, n = 323), a vitamin K antagonist (VKA, n = 69) or a direct oral anticoagulant (DOAC, n = 48). All post-PCI patients had elevated ROTEM clot stiffness values, but only the DAPT group additionally presented with a decreased fibrinolytic potential as measured with tPA ROTEM. Patients receiving anticoagulants had prolonged clotting times (CT) when compared to the control and DAPT group; EXTEM and FIBTEM CT could best discriminate between patients (not) using anticoagulants (AUC > 0.97). Furthermore, EXTEM CT was significantly prolonged in DAPT patients with bleeding complications during follow-up (68 [62–70] vs. 62 [57–68], p = 0.030).Conclusion: ROTEM CT has high potential for identifying anticoagulants and tPA ROTEM could detect a diminished fibrinolytic potential in patients using DAPT. Furthermore, the ability of EXTEM CT to identify patients at risk for bleeding may be promising and warrants further research.

Dual antithrombotic therapy on early clinical outcomes in patients with atrial fibrillation after percutaneous coronary intervention: a nationwide study in the era of NOAC

Abstract Background/Introduction Recent evidence has confirmed low bleeding risk with double antithrombotic therapy, combining oral anticoagulant (OAC) and single platelet inhibitor, in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). Among the Asian AF population, most of the patients received dual antiplatelet therapy (DAPT) without OACs, even after the introduction of non-vitamin K oral anticoagulants (NOACs). Purpose The current nationwide study assessed 3-month ischemic and bleeding risks of DAPT in comparison to triple antithrombotic therapy among the Korean AF population undergoing PCI. Methods We analyzed the claims records of 11,039 patients (mean age 70 years, 66.3% male, and mean CHA2DS2-VASc score 3.2) between 2013 to 2018. Patients were categorized into triple therapy group with vitamin K antagonists (VKAs-TT), or NOACs (NOACs-TT), and DAPT group according to the antithrombotic therapy after PCI. 3-month risks of ischemic stroke, non-fatal myocardial infarction, any in-hospital death, and major bleeding were compared between groups after baseline adjustment using inverse probability weighting. Results A total of 1,786, 1,997, and 7,256 patients were allocated to the VKAs-TT, NOACs-TT, and DAPT groups. The DAPT group had a higher prevalence of prior MI and coronary revascularization, but had lower thromboembolic and bleeding risks than the triple antithrombotic therapy groups (mean CHA2DS2-VASc score 3.8, 4.1, and 3.5; and mean HAS-BLED score 3.3, 3.4, and 3.1 for VKAs-TT, NOACs-TT, and DAPT groups, respectively). The NOACs-TT group was associated with a lower risk of ischemic stroke (hazard ratio [HR] 0.38, 95% confidence interval [CI] 0.20–0.70) and any in-hospital death (HR 0.70, 95% CI 0.49–0.98) compared with the VKAs-TT group. The DAPT group showed a lower risk of ischemic stroke (HR 0.41, 95% CI 0.27–0.63) and major bleeding (HR 0.55, 95% CI 0.37–0.84) than the VKAs-TT group, especially in patients without prior OAC treatment. The DAPT group showed a comparable ischemic risk against the NOACs-TT group, although the risk of major bleeding was lower in the DAPT group, especially among old age (HR 0.47, 95% CI 0.29–0.78) or OACs-naive patients (HR 0.50, 95% CI 0.29–0.86). Conclusion Among the Asian AF population, using short-term DAPT for 3-month after PCI was associated with a lower risk of bleeding without increasing ischemic risk compared to triple antithrombotic therapy with OAC. This may be a therapeutic option in very high bleeding risk patients who have had complex PCI necessitating focus on DAPT in the initial 3 month period. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This study was supported by grant no 3020200200 from the Seoul National University Hospital Research Fund, by the Korea Medical Device Development Fund grant funded by the Korea government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, Republic of Korea, the Ministry of Food and Drug Safety) (Project Number: 202013B14), and by the Korea National Research Foundation funded by the Ministry of Education, Science and Technology (grant 2020R1F1A106740). Figure 1Figure 2

Antithrombotic Management for Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Comprehensive protection of a patient with atrial fibrillation (AF) should not only reduce the risk of stroke and systemic embolism, but also reduce the risk coronary events and ensure high adherence to treatment. In accordance with consensus document issued by the European Heart Rhythm Association, European Society of Cardiology, European Association of Percutaneous Cardiovascular Interventions, as well as with other recent Russian Society of Cardiology Guidelines, the management of antithrombotic therapy of patients with AF undergoing percutaneous coronary intervention (PCI) requires that multiple and interconnected issues. The review article addresses questions about duration of initial triple antithrombotic therapy (TAT), selection of P2Y12 inhibitor, choice of oral anticoagulant to be combined with antiplatelet therapy, intensity of oral anticoagulation throughout combination therapy, and choice of oral anticoagulant for indefinite therapy. In general, it is recommended to refuse the routine use of TAT for most patients. Accordingly, for patients who need both anticoagulant and antiplatelet therapy, it is strongly recommended that the default strategy after recent PCI is a double antithrombotic therapy consisting of an anticoagulant and one antiplatelet, preferably from the group of P2Y12 inhibitors. When conducting combined antithrombotic therapy, preference should be given to clopidogrel compared to other, more powerful P2Y12 inhibitors and direct oral anticoagulant (DOAC) instead of vitamin K antagonists. The primary choice of DOAC in patients with AF who have undergone PCI should be carried out taking into account such factors as individual risk of stroke and bleeding, adherence to treatment, concomitant diseases, pharmacological characteristics and evidence base of a specific DOAC, taking other medications, etc. The pharmacokinetic features of rivaroxaban, which create the possibility of its single administration, the evidence base for reducing coronary risks in various variants of the course of coronary heart disease, determines the special positions of the drug for the comprehensive protection of patients with AF after PCI.

Characteristics and outcomes in patients with atrial fibrillation and acute coronary syndrome treated with ticagrelor and novel oral anticoagulants

IntroductionOptimal antithrombotic treatment after an acute coronary syndrome (ACS) in patients with atrial fibrillation is unclear. Data on outcomes in patients on concomitant ticagrelor and the novel oral anticoagulants (NOAC) is scarce. This study therefore sought to describe patient characteristics and treatment outcomes in patients with atrial fibrillation and ACS treated with concomitant ticagrelor and NOACs (double antithrombotic therapy, DT). Materials and methodsWe retrospectively identified all ACS patients with atrial fibrillation on DT upon discharge from Skåne University Hospital in Lund, Sweden, between 2016 and 2019. Identified patients were compared with age and sex matched controls with ACS alone treated with ticagrelor and aspirin (DAPT). Major bleeding was defined in accordance with the HAS-BLED derivation study. Patients were retrospectively followed for six months. ResultsIn total, 341 patients on DT were identified and compared with 341 controls on DAPT. Mean HAS-BLED bleeding risk score was higher in patients on DT (2.9 ± 1.0 vs 2.6+/0.9 units, p < 0.001; DT vs DAPT). The incidence of major bleeding was higher in patients on DT (31 (9.1%) vs 10 (2.9%), p = 0.001; DT vs DAPT), while a composite of all thrombotic events was found to be similar between the groups (8 (2.3%) vs 5 (1.5%), p = NS; DT vs DAPT). ConclusionsWhile thrombotic events occur at a similar rate, the bleeding rate is higher in patients with atrial fibrillation and ACS treated with DT than in patients with ACS alone treated with DAPT. Patients with atrial fibrillation also have a higher basal bleeding risk.

Safety and efficacy of double vs. triple antithrombotic therapy in patients with atrial fibrillation with or without acute coronary syndrome undergoing percutaneous coronary intervention： a systematic review and meta-analysis of vitamin k antagonist a

Objective: To compare the safety and efficacy of double therapy (DT) (no aspirin) versus triple therapy (TT) (with aspirin) antithrombotic drugs in patients with atrial fibrillation and acute coronary syndrome or underwent percutaneous coronary intervention (PCI).Methods: We searched PubMed, Cochrane, Scopus, and Web of Science for relevant articles from inception to December 2020. We conducted the analysis of dichotomous outcomes using risk ratio (RR) and relative 95% confidence interval (CI), while the continuous outcomes were analyzed using mean difference (MD) and relative 95% CI. Heterogeneous outcomes were analyzed with random-effects model, and homogeneous data were analyzed with fixed-effects model. We assessed the risk of bias among the included studies by using Cochrane’s risk of bias tool.Results: A total of five studies were included. Regarding Major or Minor Bleeding, the overall risk ratio was significantly lower with DT group compared with TT group (RR=0.60 [0.45, 0.81], (P = 0.07)). For the safety endpoint (TIMI major or minor bleeding, TIMI major bleeding) favored DT group over TT group, respectively (RR=0.60 [0.45, 0.81], (P = 0.07)); (RR= 0.55 [0.43, 0.70], (P &lt; 0.01)). Intracranial hemorrhage did not differ between both groups (RR=0.62 [0.37, 1.05], (P = 0.07)). The efficacy endpoint, all-cause death showed no significant difference between both groups (RR=1.08 [0.89, 1.31], (P = 0.42)). There were no significant differences between two groups in cardiovascular death, stent thrombosis, myocardial infarction and stroke, respectively (RR=1.10 [0.86, 1.41], (P = 0.43); (RR=1.40 [0.92, 2.12], (P = 0.11); (RR=1.20 [0.98, 1.49], (P = 0.08); (RR=0.95 [0.66, 1.37], (P = 0.79).; respectively).Conclusion: Compared with triple antithrombotic therapy, double antithrombotic therapy is associated with lower bleeding risks, including minor and major bleeding, but the incidence of efficacy endpoints was similar between both groups.  Â

Double antithrombotic therapy for prevention of bleeding and ischemic events after percutaneous coronary intervention in patients with atrial fibrillation: A meta-analysis.

Background:The efficacy of double antithrombotic therapy (DAT) vs. triple antithrombotic therapy (TAT) for prevention of bleeding and ischemic events in patients with atrial fibrillation following percutaneous coronary intervention (PCI) is unclear in those subgroups defined by the 5 factors (i.e., sex, age, race, history of diabetes, and type of P2Y12 inhibitor). We aimed to assess the efficacy of DAT vs TAT in these patient subgroups.Methods:We searched PubMed and relevant websites to include related randomized controlled trials (RCTs). Two endpoints of interest were clinically significant bleeding and major adverse cardiac events (MACE). Meta-analysis was performed stratified by 5 factors of interest (i.e., sex, age, race, history of diabetes, and type of P2Y12 inhibitor) to obtain pooled hazard ratio (HR) and 95% confidence interval (CI). Meta-regression analysis was conducted to evaluate subgroup effects. We detected publication bias by Egger test and funnel plots.Results:We included 4 RCTs for meta-analysis. DAT vs TAT significantly reduced the risk of clinically significant bleeding (HR 0.56, 95% CI 0.50–0.63). This effect of DAT was observed in most subgroups of interest (HR ranged from 0.54 to 0.69), and was consistent across various subgroups defined by each of the 5 factors of interest (Psubgroup ranged from 0.290 to 0.794). DAT vs TAT led to the similar risk of MACE (HR 0.98, 95% CI 0.89–1.08). This effect of DAT was observed in all subgroups of interest (all 95% CIs of HRs were across 1.0), and was consistent across various subgroups defined by each of the 5 factors of interest (Psubgroup ranged from 0.308 to 0.828). Publication bias was found only in one subgroup.Conclusions:Compared with TAT, DAT significantly reduces the risk of clinically significant bleeding and leads to the similar risk of MACE in patients with atrial fibrillation following PCI, irrespective of sex, age, race, history of diabetes, and type of P2Y12 inhibitor used at baseline.

НЕЗАВИСИМЫЕ ПРЕДИКТОРЫ И ПРОГНОЗИРОВАНИЕ ИНФАРКТА МИОКАРДА В ОТДАЛЕННОМ ПЕРИОДЕ У ПАЦИЕНТОВ С НЕСТАБИЛЬНОЙ СТЕНОКАРДИЕЙ ПОСЛЕ СТЕНТИРОВАНИЯ КОРОНАРНЫХ АРТЕРИЙ

Objective. to develop independent predictors for predicting long-term myocardial infarction (MI) in patients (pts) with unstable angina (UA) after coronary artery stenting (PCI) based on the results of a seven-year follow-up. Materials and Methods. The study involved 165 pts with UA and coronary artery stenting (PCI). PCI was performed in 3.2±1.6 days after admission to the in-patient department. Drug-coated stents (Xience V and Biomatrix) were used, the average number of stents was 2.1±0.8 per person, the average length of the stented area was 43.12±25.6 mm, and the average diameter of the implanted stents was 3.12±0.5 mm. All patients were assessed for troponin I, myeloperoxidase, and C-reactive protein levels; coagulation hemostasis was assessed; and a thrombin generation test was performed. The aggregatogram was performed on the analyzer Multiplate (ASPI-test, ADP-test). The patients underwent echocardiography, coronary angiography. Double antithrombotic therapy with clopidogrel 75 mg and acetylsalicylic acid 75 mg was prescribed for 12 months. The follow-up period was 7±1.6 years. Results. Repeated UA developed in 91 (55.2%) pts during a 7-year follow-up period, myocardial infarction was registered in 21 (12.7%) pts. Cardiovascular mortality was 7.3%. Independent predictors of MI risk included: baseline D-dimer level ≥796 ng/ml AUC 0.766 (RR 5.272; 95% CI 2,125-13,082), endogenous thrombin potential ≥2294.5 nM*min AUC 0.912 (RR 4,769; 95% CI 2,457-10,546), N-terminal fragment of brain natriuretic peptide (NTproBNP) ≥816 pg/ml AUC 0.794 (RR 1,935; 95% CI 1,218-3.075), homocysteine level ≥16 µmol/l AUC 0.707 (RR 1.971; 95% CI 1.140-3.406), highly sensitive C-reactive protein ≥6.4 g/l AUC 0.790 (RR 1.333; 95% CI 1.081-1.644), number of affected arteries≥ 3 AUC 0.714 (RR 2.129; 95% CI 1.237-2.664). The developed model for predicting myocardial infarction included the initial level of endogenous thrombin potential≥2294.5 nM * min, D-dimers ≥796 ng / ml, and the number of affected coronary arteries≥ 3. For the developed model, the AUC was 0.964, which corresponds to the excellent quality of the model. Conclusion. The prognosis of myocardial infarction in patients with unstable angina and stenting of the coronary arteries receiving the standard antiplatelet therapy involves laboratory criteria that reflect the activation of the hemostatic system and the residual thrombogenic risk.

Aspects of anticoagulant therapy in patients with atrial fibrillation in the light of updated guidelines of the European society of cardiology 2020: the position of dabigatran

This review focuses on some aspects of anticoagulant therapy in the updated clinical guidelines for atrial fibrillation of the European society of cardiology, published in 2020. Atrial fibrillation is a polymorbid continuously developing syndrome, and therefore the treatment strategy is based on a comprehensive assessment of the patient, including the risk of stroke, the presence and severity of symptoms, and an assessment of structural heart disease and comorbidities. The review describes the principles of the proposed integrated approach, abbreviated “ABC pathway”, as reflecting the three main directions of the treatment strategy. According to experts, the clinical picture of AF (i.e. first detected, paroxysmal, persistent, long-term persistent or permanent) should not determine the indications for the appointment of anticoagulant therapy. The CHA2DS2-VASc scale continues to be the basis for stratification of thromboembolic risk. The role of dabigatran in primary and secondary prevention of stroke and systemic embolism in patients with atrial fibrillation is described. Changes in the position of experts regarding the assessment of bleeding risk are highlighted in order to help identify unmodified and eliminate modifiable risk factors for bleeding, as well as to identify AF patients who are potentially at high risk of bleeding for more frequent monitoring and monitoring of their condition. Questions about the use of direct oral anticoagulants in the choice of rhythm control tactics are highlighted separately. The use of dabigatran in patients undergoing cardioversion and catheter ablation is justified. Practical questions about the continuous strategy of anticoagulant therapy during ablation are highlighted separately. Changes related to multicomponent therapy after percutaneous coronary intervention are highlighted. The main measure to improve the safety of combined antithrombotic therapy is to minimize the duration of triple therapy. The updated recommendations supportlimiting the duration of triple antithrombotic therapy to 1 month, and also provide for early discontinuation of aspirin (≤1 week) and continuation of double antithrombotic therapy in cases of uncomplicated stenting and low risk of thrombosis, or when the risk of bleeding exceeds the risk of thrombotic events.

Abstract 12786: Antithrombotic Therapy After Transcatheter Aortic Valve Implantation in Patients With Concomitant Indications for Long-term Oral Anticoagulation: A Systemic Review and Meta-analysis

Background: Ischemic and bleeding complications after transcatheter aortic valve implantation (TAVI) remain prevalent and affect survival. Atrial fibrillation (AF) is common in patients undergoing TAVI and constitutes an indication for long-term oral anticoagulation (OAC). Current guidelines on antithrombotic treatment in patients who have an indication for OAC after TAVI are based on expert opinion and suggest the use of vitamin K antagonist (VKA) either alone or in combination with aspirin or clopidogrel. Purpose: To compare OAC (VKA or direct oral anticoagulant) versus OAC in combination with single antiplatelet therapy (SAPT), either aspirin or clopidogrel, as antithrombotic treatment following TAVI in patients with an indication for long-term OAC or the prevention of cerebrovascular events, bleeding events and all-cause mortality. Methods: We systematically searched PubMed, Embase and Cochrane databases, in April 2020, for both interventional or observational studies comparing OAC with OAC plus SAPT. Random-effects meta-analysis for OAC and OAC combined with SAPT were performed. Results: Four studies were included (three registry-based and one randomized clinical trial) providing a total of 1218 patients, and 69 pooled cerebrovascular events. There was no statistical difference between OAC and OAC plus SAPT for the prevention of cerebrovascular events after TAVI (pooled OR 0.89 [0.51, 1.55], P=0.69, I 2 = 0%) - Figure. Similarly, there was a similar rate of all-cause mortality (pooled OR 0.98 [0.72, 1.35], P=0.91, I 2 = 0%). Furthermore, the rate of major bleeding or life-threatening events was significantly lower for OAC compared with the combined therapy (pooled OR 0.45 [0.29, 0.70], P&lt;0.01, I 2 = 5%). Conclusions: Our pooled data suggests that for patients with indication for long-term oral anticoagulation after TAVI, the routine use of double anti-thrombotic therapy (SAPT+OAC) compared to the use of OAC, conferred an increased risk of bleeding

Antiagregantes y anticoagulantes en el manejo de ectasia coronaria con flujo lento, una revisión de reportes de caso

La ectasia coronaria es una dilatación profusa de todo el segmento arterial. Aún no se ha determinado la terapia más adecuada para el proceso trombogénico que acompaña a la ectasia coronaria, por lo que el objetivo de este estudio es establecer si las terapias: antitrombótica doble (TAPS+ACO), triple (TAPD+ACO) o solo con anticoagulante oral (ACO) son útiles para prevenir la recidiva de los síntomas. Se realizó una búsqueda de reportes de casos sobre ectasia coronaria y manejo con anticoagulantes y/o antiagregantes para la prevención de recidivas, publicados desde 1997 hasta mayo de 2020. Se incluyeron 11 reportes. Cinco pacientes recibieron terapia antitrombótica triple (TAPD+ACO), tres pacientes recibieron terapia antitrombótica doble (TAPS+ACO) y tres pacientes recibieron terapia solo con anticoagulante oral (ACO). Ninguno tuvo recurrencias en el periodo de seguimiento. Tanto la terapia solo con ACO, como la terapia antitrombótica doble (ACO + TAP) y triple (ACO + TAPD) mostraron beneficio al prevenir las recurrencias de síndrome coronario agudo (SCA) tras el seguimiento como mínimo de 3 meses. La terapia antitrombótica triple parece ser más eficaz que el uso de TAPD de manera aislada. El uso de nuevos anticoagulantes orales (NACO) podría tener mayor beneficio sobre el uso de los tradicionales. Sin embargo, se requieren más estudios al respecto.

Safety and Efficacy of Double Antithrombotic Therapy With Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis.

BackgroundThe optimal antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention is a topic of debate. We aimed at defining the efficacy and safety of double antithrombotic therapy with single antiplatelet therapy (SAPT) plus a non–vitamin K antagonist oral anticoagulant (NOAC) against triple antithrombotic therapy with dual antiplatelet therapy (DAPT) added to a vitamin K antagonist (VKA), illustrating the pooled cumulative distribution of events, the ranking of different NOACs tested in NOAC+SAPT combination strategies, and the state of the current evidence in the field.Methods and ResultsRandomized controlled trials meeting the inclusion criteria were identified. The primary efficacy end point was the composite of trial‐defined major adverse cardiac events. The primary safety end point was clinically significant bleeding. Secondary end points were the components of primary end points. Trial‐level pairwise and Bayesian network meta‐analyses, reconstructed Kaplan–Meier analyses, and trial sequential analysis were performed. Four randomized controlled trials (10 969 patients) were included. No differences were found in terms of major adverse cardiac events (hazard ratio [HR], 1.07; 95% CI, 0.94–1.22), and the NOAC+SAPT strategy showed a lower rate of clinically significant bleeding compared with VKA + DAPT (HR, 0.56; 95% CI, 0.39–0.80). These results were consistent in reconstructed Kaplan–Meier analyses. In the Bayesian network meta‐analysis, different NOACs displayed diverse risk–benefit profiles. Trial sequential analyses suggest that the evidence for the similarity in major adverse cardiac events compared with VKA + DAPT and the bleeding risk reduction observed with NOAC+SAPT is likely to be conclusive.ConclusionsNOAC+SAPT does not increase the risk of major adverse cardiac events and reduces the risk of bleeding compared with VKA + DAPT in AF patients undergoing percutaneous coronary intervention. Various NOACs may have different risk–benefit profiles in combination strategies.RegistrationURL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020151089.

Double Antithrombotic versus Triple Antithrombotic Therapy in Patients with Atrial Fibrillation and Acute Coronary Syndrome.

In atrial fibrillation (AF), oral anticoagulant (OAC) therapy with either vitamin K antagonist or non-vitamin K antagonist is used to prevent thromboembolic complications. In patients who presented with acute coronary syndrome (ACS) and were treated by percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) with aspirin and a P2Y 12 inhibitor reduces major adverse cardiac events (MACEs) and stent thrombosis. Consequently, in patients with AF who presented with ACS and were treated by PCI, the combination of OAC and DAPT, the so-called triple antithrombotic therapy (TAT) is needed to improve the outcome of the patients. However, the use of TAT increases the risk of bleeding. Several randomized clinical trials and a meta-analysis evaluated the use of TAT and double antithrombotic therapy (DAT) in this population, and DAT is defined as patients who receive combination of one antiplatelet and OAC. In general, the studies demonstrated a reduction in bleeding event in patients who received DAT as compared with TAT, with similar incidence of thromboembolic complications and MACE. To date, there is no established consensus or guideline for the most appropriate combination of antithrombotic agents in patients with AF and ACS who undergo PCI. Tailoring the treatment for each individual is likely the best approach to determine the balance of bleeding risk and ischemic events before starting antithrombotic therapy. Future trials with adequate sample size are needed to find the most appropriate combination of antiplatelet and OAC in patients with AF who presented with ACS and treated by PCI.

Anticoagulant and anti-thrombotic therapy in acute type B aortic dissection: when real-life scenarios face the shadows of the evidence-based medicine

BackgroundEvidence-based recommendations about anticoagulation in acute type B aortic dissection (TBAD) are completely missing, but there is a diffuse conviction that it could prevent the healing process of the dissected aorta’s false lumen. However, several clinical conditions may lead to the necessity to start anticoagulant therapy among patients with acute type B aortic dissection, ranging from atrial fibrillation to more complicated clinical scenarios and the correct management in this kind of patients is still an open issue.Case presentationWe are presenting a 51-years-old man with multi-infarct encephalopathy referred to us for an acute TBAD and a first diagnosis of ischemic cardiomyopathy complicated by left ventricular (LV) thrombus formation. Coronary angiography revealed a critical stenosis of left anterior descending artery (LAD) treated with drug-eluting stent deployment. The patient was addressed to triple antithrombotic therapy with acetylsalicylic acid, clopidogrel and warfarin with target INR 2.0–2.5. After 6 months, computed tomography angiography revealed the stability of the dissection flap. Cardiac magnetic resonance imaging, however, confirmed the persistence of a small thrombotic formation in LV apex, thus double antithrombotic therapy with warfarin and clopidogrel was instituted. The patient remained asymptomatic during the follow-up period but was advised to suspend his job and physical activities.ConclusionCurrent guidelines do not discuss anticoagulant therapy in the setting of TBAD and large randomized trials are lacking. Despite it is generally considered unsafe to administer anticoagulants in patients with TBAD, we present a case in which triple antithrombotic therapy was well tolerated and did not lead to progression of the intimal flap after 6 months.

Acute coronary syndrome in a patient with transient ischemic attack: challenges of antithrombotic therapy (a clinical case)

The paper presents experience with antithrombotic therapy in a critically ill patient with acute coronary syndrome and transient ischemic attack. It characterizes problems in triple antithrombotic therapy in a very ill patient with comorbidity. The paper demonstrates an incremental approach to choosing therapy according to the clinical picture of disease, an assessment of risk factors for ischemic and hemorrhagic complications over time, which is very important in the routine practice of a physician. It also shows how, based on existing recommendations, the optimal anticoagulant is chosen as part of triple and double antithrombotic therapy in terms of its potential risks and possible complications.