In the era of drug-eluting stents (DES), a long-term dual antiplatelet therapy is required to prevent late stent thrombosis. However, in patients with atrial fibrillation (AF), there is a concern that combining warfarin with dual antiplatelet therapy may increase the risk of bleeding. We analyzed 1274 consecutive patients with coronary artery disease who were treated with coronary intervention from January 2006 through January 2009. Of these, we enrolled 74 AF patients treated with DES and dual antiplatelet therapy as well as warfarin. The primary endpoint was the incidence of major bleeding within 3 years; the predictive factor of major bleeding was also analyzed. To evaluate the efficacy of anticoagulant therapy, time in therapeutic range (TTR) was also measured. The 3-year incidence of major bleeding was 12.2 % (nine of 74 patients). The average observation period was 25.7 ± 20.2 months. Mean TTR value was 44.6 ± 33.0 % and was maintained at a relatively low level. Multivariate analysis revealed that a higher CHADS2 score (2-point more) was an independent predictor of increased risk of major bleeding. Major bleeding in the patients with triple antithrombotic therapy including warfarin occurred at a relatively high rate. Although the higher CHADS2-score indicates a high risk of thrombotic events, it was strongly associated with bleeding complications.
At present, there is consensus that prolonged dual antiplatelet therapy (DAPT) is effective to reduce cardiovascular events at the expense of bleeding complication events. A causal relationship of prolonged DAPT with an increase in mortality remains debatable, however, it appears to be obvious that bleeding complications are associated with an increase in cardiac events. Thus, individualized optimal DAPT duration balancing the risk and benefit of DAPT should be applied. In addition, strategy to minimize bleeding complications is highly recommended. Several risk scores have been reported to discriminate the risk and benefits of DAPT. However, in general, bleeding risk and event risk are correlated with each other, thus predictability of these scores is limited to moderate. Therefore, interpretation of previous trials is important to overcome the shortcome in outcomes. In this review, we provide an overview of DAPT trials and clarify the shortfalls to consider in Japan. Finally, possible future trends with reference to the results of recent clinical trials will be presented.
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