Antithrombotic Therapy for Atrial Fibrillation with Stable Coronary Disease

Yasuda, Satoshi; Kaikita, Koichi; Akao, Masaharu; Ako, Junya; Matoba, Tetsuya; Nakamura, Masato; Miyauchi, Katsumi; Hagiwara, Nobuhisa; Kimura, Kazuo; Hirayama, Atsushi; Matsui, Kunihiko; Ogawa, Hisao

doi:10.1056/nejmoa1904143

Cited by 369 publications

(261 citation statements)

References 19 publications

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“…For AF patients such as those included in this case series, current European guidelines recommend chronic OAC alone [1]. This recommendation is supported by registry data [10][11][12], and has been recently reinforced by the results of two randomized trials [5,13]. In the OAC-ALONE trial, the efficacy and safety of OAC monotherapy compared with dual antithrombotic therapy with OAC and an antiplatelet was investigated in patients with AF and long-standing CCS (i.e., beyond 1 year after coronary stenting) [13].…”

Section: Discussionmentioning

confidence: 66%

“…The trial failed to establish non-inferiority of OAC alone likely due to low power because patient enrollment was prematurely terminated due to slow recruitment. In the AFIRE trial, rivaroxaban monotherapy was non-inferior to combination therapy with ASA for efficacy and was superior for safety in a similar, larger population [5]. The trial was discontinued early because of increased mortality in the combination-therapy group.…”

Section: Discussionmentioning

confidence: 99%

“…When these patients have AF, it is broadly accepted that OAC should be continued alone, without concomitant antiplatelet therapy [1,3,4]. The AFIRE trial recently showed that adding ASA to OAC monotherapy exposes patients to an unacceptable and possibly life-threatening increased risk of bleeding [5]. However, some physicians are afraid that routinely stopping any antiplatelet therapy would expose some patients to the risk of catastrophic consequences that outweigh the risk of bleeding, e.g., those with prior PCI of the left main or the proximal left anterior descending artery (LAD).…”

Section: Introductionmentioning

confidence: 99%

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Mechanisms of ST-segment elevation myocardial infarction in patients with atrial fibrillation, prior stenting and long-standing chronic coronary syndrome

et al. 2020

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Background: The optimal antithrombotic regimen for patients with atrial fibrillation (AF) and chronic coronary syndromes beyond 1 year after percutaneous coronary intervention (PCI) is a matter of debate. For these patients, guidelines recommend oral anticoagulation (OAC) alone, but the risk of thrombotic complications remains a concern. The aim of this study was to characterize the incidence, presentation and use of antithrombotic therapy in patients with AF, prior stenting > 12 months and new ST-segment elevation myocardial infarction (STEMI). Methods: Consecutive patients were selected from an institutional registry over a 3-year period if they matched the following criteria: 1) STEMI undergoing primary PCI; 2) AF; 3) chronic coronary syndrome with prior stenting > 12 months. Results: Among 852 consecutive STEMI patients undergoing primary PCI, the prevalence of AF was 4.1%, and 6 (0.9%) patients met all the inclusion criteria. Substantial heterogeneity in antithrombotic treatment for these patients was noted (e.g., OAC alone, OAC plus a single antiplatelet agent, no antithrombotic therapy). In 50% of patients, the STEMI episode was linked to a previously stented lesion or documented plaque. Conclusions: This case review illustrates the wide heterogeneity in antithrombotic pharmacotherapy among AF patients presenting with STEMI > 12 months after PCI. The underlying reason for STEMI is only partly related to disease progression or stent-related events. This finding suggests that multiple mechanisms of recurrence may be advocated, and are not only limited to antithrombotic therapy but may be explained by the natural history of coronary artery disease in remote vessels. (Cardiol J 2020; 27, 1: 8-15)

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Section: Discussionmentioning

confidence: 66%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Mechanisms of ST-segment elevation myocardial infarction in patients with atrial fibrillation, prior stenting and long-standing chronic coronary syndrome

et al. 2020

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“…25,26 Aspirin may be resumed once the P2Y12 inhibitor is stopped, although recent data show that rivaroxaban monotherapy is safe and adequate in patients with stable CAD and atrial fibrillation. 31 Monitor patients closely in the first 90 days after P2Y12 discontinuation for recurrent ischemic events. 32 Statins: High-intensity statin therapy (goal LDL-C < 70 mg/dL) is recommended after ACS for pleiotropic effects, 3,9,18,19 but older adults have a greater risk of statin-associated muscle symptoms and moderate-intensity statin therapy may be preferred.…”

Section: Triple Therapy In Patients Requiring Long-term Oral Anticoagmentioning

confidence: 99%

“…Recent trials have shown that aspirin may be safely omitted while continuing dual therapy with an anticoagulant and P2Y12 receptor antagonist . Aspirin may be resumed once the P2Y12 inhibitor is stopped, although recent data show that rivaroxaban monotherapy is safe and adequate in patients with stable CAD and atrial fibrillation . Monitor patients closely in the first 90 days after P2Y12 discontinuation for recurrent ischemic events …”

Section: Introductionmentioning

confidence: 99%

Towards appropriate polypharmacy in older cardiovascular patients: How many medications do I have to take?

Moulder

Hendricks

2019

Clinical Cardiology

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Background Polypharmacy in older adults leads to increased risks of side effects and drug‐drug interactions, affecting their health outcomes and quality of life. Deprescribing, the act of simplifying medication regimens, is challenging due to the lack of consensus guidelines. Hypothesis To offer some guidance on managing medication regimens for older cardiovascular patients. Methods We reviewed the most recent pertinent guidelines and literature. Results This review provides practical considerations for appropriate prescribing in the older population with cardiovascular disease in order to strike a balance between unnecessary or harmful medications and therapies with proven long‐term benefits. Conclusion On‐going dialogue between healthcare providers and patients allows close monitoring of medication effectiveness and prevention of side effects. Medication regimens require individualization, as patients' goals of care change with advancing age.

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Efficacy and Safety Considerations With Dose-Reduced Direct Oral Anticoagulants

et al. 2022

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IMPORTANCE Dose-reduced regimens of direct oral anticoagulants (DOACs) may be used for 2 main purposes: dose-adjusted treatment intended as full-intensity anticoagulation (eg, for stroke prevention in atrial fibrillation [AF] in patients requiring dose reduction) or low-intensity treatment (eg, extended-duration treatment of venous thromboembolism [VTE]). We reviewed randomized clinical trials (RCTs) to understand the scenarios in which dose-adjusted or low-intensity DOACs were tested and reviewed the labeled indications by regulatory authorities, using data from large registries to assess whether the use of dose-reduced DOACs in routine practice aligned with the findings of RCTs. OBSERVATIONS Among 4191 screened publications, 35 RCTs that used dose-adjusted DOACs were identified for dabigatran, apixaban, rivaroxaban, and edoxaban. Of these 35 RCTs, 29 were related to stroke prevention in AF. Efficacy and safety results for dose-adjusted DOACs in large RCTs of AF were similar to those found for full-dose DOACs. To our knowledge, dabigatran, apixaban, and rivaroxaban have not been studied as dose-adjusted therapy for acute VTE treatment. Low-intensity DOACs were identified in 37 RCTs. Low-intensity DOACs may be used for extended-duration treatment of VTE (apixaban and rivaroxaban), primary prevention in orthopedic surgeries (dabigatran, apixaban, and rivaroxaban), primary prevention in ambulatory high-risk cancer patients (apixaban and rivaroxaban) or (postdischarge) high-risk medical patients (rivaroxaban), in stable atherosclerotic vascular disease, or after a recent revascularization for peripheral artery disease in conjunction with aspirin (rivaroxaban). Minor variations exist between regulatory authorities in different regions regarding criteria for dose adjustment of DOACs. Data from large registries indicated that dose-reduced DOACs were used occasionally with doses or for clinical scenarios different from those studied in RCTs or recommended by regulatory authorities.CONCLUSIONS AND RELEVANCE Dose adjustment and low-intensity treatment are 2 different forms of dose-reduced DOACs. Dose adjustment is mostly relevant for AF and should be done based on the approved criteria. Dose adjustment of DOACs should not be used for acute VTE treatment in most cases. In contrast, low-intensity DOACs may be used for primary or secondary VTE prevention for studied and approved indications. Attention should be given to routine practice patterns to align the daily clinical practice with existing evidence of safety and efficacy.

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Antithrombotic Therapy for Atrial Fibrillation with Stable Coronary Disease

Cited by 369 publications

References 19 publications

Mechanisms of ST-segment elevation myocardial infarction in patients with atrial fibrillation, prior stenting and long-standing chronic coronary syndrome

Mechanisms of ST-segment elevation myocardial infarction in patients with atrial fibrillation, prior stenting and long-standing chronic coronary syndrome

Towards appropriate polypharmacy in older cardiovascular patients: How many medications do I have to take?

Efficacy and Safety Considerations With Dose-Reduced Direct Oral Anticoagulants

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