Combined anticoagulation and antiplatelet therapy for high-risk patients with atrial fibrillation: a systematic review

Lane, Deirdre A.; Raichand, Smriti; Moore, David; Connock, Martin; Fry‐Smith, A; Fitzmaurice, DA

doi:10.3310/hta17300

Cited by 29 publications

(19 citation statements)

References 43 publications

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“…The trade‐off between benefit and safety of adding SAPT to an anticoagulant in patients with both AF and CAD or others at risk of an acute coronary event is often challenging for clinicians 9, 10. A meta‐analysis of 10 randomized trials comparing the combination of an oral anticoagulant and aspirin with anticoagulant alone in patients with AF at risk of coronary events showed no reduction in arterial thromboembolic events in favor of the combination, but did show an increased risk of major bleeding 20.…”

Section: Discussionmentioning

confidence: 99%

“…Though oral anticoagulants are more effective than antiplatelet agents in preventing stroke/SEE in patients with AF, it is thought that the latter may be more protective in reducing vascular events in patients with CAD or at high risk of acute coronary events 4, 5. The choice of optimal antithrombotic management to prevent both thromboembolic and acute ischemic events in patients with AF and coexisting CAD is challenging given that combination therapy of anticoagulant and ‐antiplatelet agents is associated with an increased risk of bleeding and its efficacy is not clear 6, 7, 8, 9, 10. Here, we report on the effects of single antiplatelet therapy (SAPT) on the comparison of edoxaban with warfarin in patients with non‐valvular AF.…”

Section: Introductionmentioning

confidence: 99%

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Concomitant Use of Single Antiplatelet Therapy With Edoxaban or Warfarin in Patients With Atrial Fibrillation: Analysis From the ENGAGE AF‐TIMI48 Trial

Ruff

Giugliano

et al. 2016

JAHA

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BackgroundWe studied the concomitant use of single antiplatelet therapy (SAPT) on the efficacy and safety of the anti‐Xa agent edoxaban in patients with atrial fibrillation (AF).Methods and Results ENGAGE AF‐TIMI 48 was a randomized trial that compared 2 dose regimens of edoxaban with warfarin. We studied both the approved high‐dose edoxaban regimen (HDER; 60 mg daily reduced by one half in patients with anticipated increased drug exposure), as well as a lower‐dose edoxaban regimen (LDER; 30 mg daily, also reduced by one half in patients with anticipated increased drug regimen). SAPT (aspirin in 92.5%) was administered at the discretion of the treating physician. Cox proportional hazard regressions stratified by SAPT at 3 months with treatment as a covariate were performed. The 4912 patients who received SAPT were more frequently male, with histories of coronary artery disease and diabetes, and had higher CHADS 2Vasc and HAS BLED scores than did the 14 977 patients not receiving SAPT. When compared to patients not receiving SAPT, those receiving SAPT had a higher incidence of major bleeding; (adjusted hazard ratio [HR adj]=1.46; 95% CI, 1.27–1.67, P<0.001). SAPT did not alter the relative efficacy of edoxaban compared to warfarin in preventing stroke or systemic embolic events (SEEs): edoxaban versus warfarin without SAPT, hazard ratio (HR adj for HDER)=0.94; (95% CI: 0.77–1.15) with SAPT, HR adj=0.70 (95% CI: 0.50–0.98), P interaction (P int)=0.14. (HR adj for LDER versus warfarin without SAPT=1.19 (95% CI 0.99–1.43) With SAPT, 1.03 (95% CI, 0.76–1.39) P int=0.42. Major bleeding was lower with edoxaban than warfarin both without SAPT, HR adj for HDER=0.80 (95% CI, 0.68–0.95), and with SAPT, HR adj=0.82 (95% CI, 0.65–1.03; P int=0.91). For LDER without SAPT (HR adj=0.56 [95% CI 0.46–0.67]) and with SAPT (HR adj=0.51 [95% CI 0.39–0.66]).ConclusionsPatients with AF who were selected by their physicians to receive SAPT in addition to an anticoagulant had a similar risk of stroke/SEE and higher rates of bleeding than those not receiving SAPT. Edoxaban exhibited similar relative efficacy and reduced bleeding compared to warfarin, with or without concomitant SAPT.Clinical Trial Registration URL: http://www.clinicaltrials.gov/. Unique identifier: NCT00781391.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Concomitant Use of Single Antiplatelet Therapy With Edoxaban or Warfarin in Patients With Atrial Fibrillation: Analysis From the ENGAGE AF‐TIMI48 Trial

Ruff

Giugliano

et al. 2016

JAHA

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“…Available evidence regarding the association between antiplatelet and an anticoagulant drugs such as aspirin and heparin is not conclusive about the risks and benefits of combining anticoagulant and antiplatelet medications to reduce cardiovascular events. That is to say that there is no consensus about the harmful effects of combined use (Lane et al, 2013;Massel, Little, 2013). There is also considerable debate about the negative impact of the combined use of proton-pump inhibitors and clopidogrel, one of the most frequent major pDDI.…”

Section: Discussionmentioning

confidence: 99%

Does hospital admission provide an opportunity for improving pharmacotherapy among elderly inpatients?

Melo

Storpirtis

Ribeiro

2016

Braz. J. Pharm. Sci.

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The purpose of the work was to assess the incidence of potential drug interactions (pDDI), major pDDI, and the use of potentially inappropriate medication (PIM) at hospital admission, during hospitalization, and at discharge to evaluate whether hospital admission provides an opportunity for improving pharmacotherapy in elderly patients at a University hospital that has a clinical pharmacist. A prospective cohort study was carried out using data from the medical records of patients admitted to an internal medicine ward. All admissions and prescriptions were monitored between March and August 2006. Micromedex® DrugReax® and Beers Criteria 2015 were used to identify pDDI, major pDDI, and PIMs, respectively. A comparison of admission and discharge prescriptions showed the following: an increase in the proportion of patients using antithrombotic agents (76 versus 144; p<0.001), lipid modifying agents (58 versus 81; p=0.024), drugs for acid-related disorders (99 versus 152; p<0.001), and particularly omeprazole (61 versus 87; p=0.015); a decrease in the number of patients prescribed psycholeptics (73 versus 32; p<0.001) and diazepam (54 versus 13; p<0.001); and a decrease in the proportion of patients exposed to polypharmacy (16.1% versus 10.1%; p=0.025), at least one pDDI (44.5% versus 32.8%; p=0.002), major pDDI (19.9% versus 12.2%; p=0.010) or PIM (85.8% versus 51.9%; p<0.001). The conclusion is that admission to a hospital ward that has a clinical pharmacist was associated with a reduction in the number of patients exposed to polypharmacy, pDDI, major pDDI, and the use of PIMs among elderly inpatients.Uniterms:. Health Services/elderly patients. Internal Medicine/hospitals. Clinical Pharmacy. Drug interactions. Drug prescriptions.

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“…Однако доля пациентов с кровотечениями в группе НОАК+антиагрегант (9,4%) была меньше, чем в группе варфарин+антиагрегант (11,8%). Авторы более крупного систематического обзора, включавшего 53 исследования разного дизайна, в том числе 11 РКИ, пришли к заключению, что в настоящее время недо-статочно доказательств пользы от добавления анти-агрегантов к антикоагулянтам, но рекомендовали про-ведение дальнейших исследований у больных ФП с вы-соким риском тромбоэмболических осложнений [31].…”

Section: Antiplatelet Therapy Of Atrial Fibrillation In the Elderlyunclassified

Antiplatelet Therapy of Atrial Fibrillation: Focus on the Elderly

Ушкалова

Zyryanov

Dumchenko

2017

Racionalʹnaâ farmakoterapiâ v kardiologii

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ВведениеИсторически антиагреганты рассматривалась в ка-честве более безопасной альтернативы антикоагулян-там у больных с фибрилляцией предсердий (ФП) с низ-ким или умеренным риском развития инсульта [1,2]. Несмотря на то, что в современных руководствах при-менение антиагрегантов не рекомендуется, в широкой медицинской практике они продолжают оставаться широко назначаемыми препаратами, особенно па-циентам с высоким риском кровотечения, включая лиц пожилого и старческого возраста [3][4][5][6][7].Эффективность и безопасность антиагрегантов у пациентов с фибрилляцией предсердий Единственным антиагрегантом, относительно хорошо изученным в рандомизированных контролируемых исследованиях (РКИ) у больных с ФП, является аце-тилсалициловая кислота (АСК). Низкие дозы АСК (≤100 мг/сут) существенно не снижали риск развития инсульта [8]. Данные об эффективности средних доз (>100 мг и ≤300 мг) более противоречивы. В боль-шинстве РКИ их применение ассоциировалось с не-большим снижением риска нефатального инсульта по сравнению с отсутствием лечения, но сопровожда-лось повышением риска серьезных внечерепных кро- Антиагреганты в терапии фибрилляции предсердий: фокус на пожилыхЕлена Андреевна Ушкалова*, Сергей Кенсаринович Зырянов, Екатерина Владимировна Думченко Российский университет дружбы народов. Россия 117198, Москва, ул. Миклухо-Маклая, 6В современных руководствах по лечению фибрилляции предсердий (ФП) в качестве препаратов выбора для профилактики инсульта ре-комендуют антикоагулянты, однако в реальной медицинской практике пожилым пациентам часто назначают антиагреганты. Обзор клинических и фармакоэпидемиологических исследований позволяет прийти к заключению, что риск, связанный с применением ацетилсалициловой кислоты (АСК) у пациентов в возрасте ≥75 лет, может превышать потенциальную пользу. Другие антиагреганты плохо изучены у больных ФП. Вопрос о назначении двойной антиагрегантной терапии (АСК+клопидогрел) может быть рассмотрен у пациентов с сопутствующими сердечно-сосудистыми заболеваниями, которые не подходят для антикоагулянтной терапии по каким-либо другим причинам, помимо рис-ка кровотечений, или у пациентов, отказывающихся принимать антикоагулянты. Комбинации антиагрегантов с варфарином или новыми пероральными антикоагулянтами не приводят к снижению риска развития инсульта по сравнению с монотерапией антикоагулянтами, но ассоциируются с более высоким риском кровотечений, поэтому не могут быть рекомендованы. Current guidelines for the management of atrial fibrillation (AF) recommend using anticoagulants as first-line drugs for stroke prevention, but in real medical practice antiplatelet drugs are often prescribed to elderly patients. Review of clinical and pharmacoepidemiological studies allows us to conclude that risk associated with acetylsalicylic acid (ASA) use in patients ≥75 years can overweigh its potential benefit. Other antiplatelet drugs are poorly studied in patients with AF. Dual antiplatelet therapy (ASA + clopidogrel) can be prescribed to elderly patients with cardiovascular comorbidity who are deemed un...

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Combined anticoagulation and antiplatelet therapy for high-risk patients with atrial fibrillation: a systematic review

Cited by 29 publications

References 43 publications

Concomitant Use of Single Antiplatelet Therapy With Edoxaban or Warfarin in Patients With Atrial Fibrillation: Analysis From the ENGAGE AF‐TIMI48 Trial

Concomitant Use of Single Antiplatelet Therapy With Edoxaban or Warfarin in Patients With Atrial Fibrillation: Analysis From the ENGAGE AF‐TIMI48 Trial

Does hospital admission provide an opportunity for improving pharmacotherapy among elderly inpatients?

Antiplatelet Therapy of Atrial Fibrillation: Focus on the Elderly

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