Bleeding After Initiation of Multiple Antithrombotic Drugs, Including Triple Therapy, in Atrial Fibrillation Patients Following Myocardial Infarction and Coronary Intervention

Abstract

Background-Uncertainty remains over optimal antithrombotic treatment of patients with atrial fibrillation presenting with myocardial infarction and/or undergoing percutaneous coronary intervention. We investigated the risk and time frame for bleeding following myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation according to antithrombotic treatment. Methods and Results-Patients

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…LEKAMI PRZECIWZAKRZEPOWYMI I LEKAMI PRZECIWPŁYTKOWYMI Przebyty zawał serca stwierdza się u około 15% pacjentów z AF uczestniczących we współczesnych próbach klinicznych [513] i rejestrach [514][515][516]. U 5-15% pacjentów z AF w którymś momencie ich życia będzie konieczne stentowanie.…”

Design and Rationale of the RE‐DUAL PCI Trial: A Prospective, Randomized, Phase 3b Study Comparing the Safety and Efficacy of Dual Antithrombotic Therapy With Dabigatran Etexilate Versus Warfarin Triple Therapy in Patients With Nonvalvular Atrial Fibrillation Who Have Undergone Percutaneous Coronary Intervention With Stenting

“…As noted above, antiplatelet monotherapy is not sufficient for stroke prevention, nor is dual antiplatelet therapy alone (although this has not been tested with the more potent drugs). On the other end of the spectrum, use of triple antithrombotic therapy for 1 year has an unacceptable increased risk of bleeding 13, 20, 36…”

“…Indeed, because blockade of P2Y 12 receptor–mediated signaling with clopidogrel is associated with greater platelet‐inhibitory effects than cyclooxygenase‐1 inhibition with aspirin, as well as the established role of P2Y 12 receptor blockade on recurrent thrombotic events, clopidogrel might be expected to be more effective than aspirin at reducing risk of ST, with a potentially lower rate of gastrointestinal bleeding as well 40. A few retrospective cohorts have observed a lower incidence of ST with clopidogrel plus warfarin dual antithrombotic therapy,13, 20, 41 and clopidogrel, aspirin, and warfarin triple antithrombotic therapy,42 compared with warfarin and aspirin dual antithrombotic therapy.…”

“…Not surprisingly, these potent regimens are associated with very high rates of major bleeding. Several large registries reported that the risk of major bleeding with triple antithrombotic therapy is 3‐fold to 4‐fold higher than with OAC alone or single antiplatelet therapy 10, 11, 12, 13. In addition, major bleeding is associated with an up to 5‐fold increased risk of death following an acute coronary syndrome (ACS) 14, 15.…”

Anticoagulation management in nonvalvular atrial fibrillation: current and future directions

“…14 Post-ACS treatment of an AF patient who underwent a PCI with stenting should be highly personalized, based on the individual atherothrombotic, thromboembolic, and bleeding risks which should be estimated using the GRACE, CHA 2 DS 2 -VASc and HASBLED scores. 1,69 Balancing the risk of stroke/systemic embolism (which is best reduced by oral anticoagulant therapy, with superior efficacy compared with any other antithrombotic treatment) 70 and stent thrombosis or recurrent ischemic events (best reduced using dual antiplatelet therapy) 71,72 vs. the risk of bleeding (which is the highest with triple antithrombotic therapy), 72 triple therapy (i.e., oral anticoagulation with a lower target INR of 2.0 to 2.5 and aspirin plus clopidogrel) is generally prescribed as short as possible depending on the stent type, followed by an oral anticoagulant plus 1 antiplatelet agent and, ultimately, an oral anticoagulant long-term monotherapy. [64][65][66] However, these recommendations are based mostly on the expert consensus opinion.…”