Antithrombotic Therapy in Patients with Acute Coronary Syndrome in the Intermountain Heart Collaborative Study

Abstract

Objective. To determine factors associated with single antiplatelet (SAP) or dual antiplatelet (DAP) therapy and anticoagulants (AC) use in hospital and after discharge among patients with acute coronary syndrome (ACS). Methods. We evaluated 5,294 ACS patients in the Intermountain Heart Collaborative Study from 2004 to 2009. Multivariable logistic regressions were used to determine predictors of AC or AP use. Results. In hospital, 99% received an AC, 79% DAP, and 19% SAP; 78% had DAP + AC. Coronary stents were the strongest predictors of DAP use in hospital compared to SAP (P < 0.001). After discharge, 77% received DAP, 20% SAP, and 9% AC; 5% had DAP + AC. DAP compared to SAP was less likely for patients on AC (odds ratio [OR] = 0.30, P < 0.0001) after discharge. Placement of a stent increased the likelihood of DAP (bare metal: OR = 54.8, P < 0.0001; drug eluting: OR = 59.4, P < 0.0001). 923 had atrial fibrillation and 337 had a history of venous thromboembolism; these patients had increased use of AC (29% and 40%, resp.). Conclusion. While in-hospital use of AC was nearly universal, postdischarge AC use was rare. Concern for providing the best antithrombotic therapy, while maintaining an acceptable bleeding risk, may explain the selection decisions.

Anticoagulants and Osteoporosis

“…Consequently, bleeding risk is one of the most important limits and discomforts in long-term VKA treatments [11,12,13]. The numerous indications for VKA therapy [6,9,14,15,16] are reported in Table 1.…”

Short- and long-term follow-up of antithrombotic management patterns in patients hospitalized with acute coronary syndrome: Indian subgroup of EPICOR Asia study

“…Warfarin was prescribed in 2.1% of patients at discharge. The use of DAPTs is associated with a lower incidence of major CV events and bleeding complications compared with the use of SAPT 18 . A review reported that use of DAPT with clopidogrel and aspirin reduced the risk of CV death, MI, or stroke to a significant extent ( p = 0.031) 19 .…”

Adverse cardiovascular events in acute coronary syndrome with indications for anticoagulation

“…The overall equalization of outcomes among AT strategies, in this interpretation, indicates the aggregate success of these clinical decisions. The clinical decision making process involves a myriad of individual patient clinical factors, but also includes current guidelines and recommendations [Zeymer et al 2013; Knight et al 2015]. In our study of ACS patients, for those who received a stent, a majority (62%) were given DAP and, for those who had a CABG, 53% were given SAP.…”

“…Current guidelines recommend the use of aspirin and a thienopyridene, or ‘dual antiplatelet therapy’ (DAP) for the majority of patients following an acute coronary syndrome (ACS) [Vandvik et al 2012]. For the most part, physicians follow these recommendations [Zeymer et al 2013; Maier et al 2014; Potpara et al 2014; Knight et al 2015]. However, many ACS patients have comorbidities [e.g.…”

“…The well-documented increase in the risk of major bleeding with combined DAP and AC [Orford et al 2004; Mattichak et al 2005; Khurram et al 2006; Lamberts et al 2012; Dewilde et al 2013; Rubboli et al 2014] often accounts for physicians’ reluctance to prescribe three antithrombotic (AT) agents and instead use more conservative strategies. A recent observational study confirmed that ACS patients prescribed AC medication were three times more likely to be prescribed a single antiplatelet (SAP) than DAP therapy [Knight et al 2015]. However, there is evidence that use of combined DAP and AC is on the rise [Maier et al 2014] and currently between 40% and 50% of patients with both ACS and AF are prescribed DAP and AC [Maier et al 2014; Potpara et al 2014].…”