Dual Antiplatelet Therapy and Outcomes in Patients With Atrial Fibrillation and Acute Coronary Syndromes Managed Medically Without Revascularization: Insights From the TRILOGY ACS Trial

Abstract

Associations between atrial fibrillation (AF), outcomes, and response to antiplatelet therapies in patients with acute coronary syndrome (ACS) managed medically without revascularization remain uncertain. We examined these associations for medically managed ACS patients randomized to dual antiplatelet therapy (DAPT) using patient data from the TRILOGY ACS trial. DAPT included aspirin plus clopidogrel 75 mg/d or prasugrel 10 mg/d (5 mg/d for those <60 kg or age ≥75 years). Patients receiving oral anticoagulants were excluded. Cox proportional hazards regression modeling was used to characterize associations between patients with AF (AF+) vs those without (AF−) and risk of ischemic and bleeding events, and to explore effects of randomized treatment on outcomes. Among 9101 patients with baseline AF status, 710 (7.8%) had AF. AF+ patients were older and had more comorbidities. Unadjusted associations of the composite of cardiovascular death/myocardial infarction/stroke were significantly higher among AF patients at 30 months (31.1% vs 18.4%; HR: 1.61, 95% CI: 1.35-1.92, P < 0.001), but differences did not persist after adjustment (HR: 1.16, 95% CI: 0.97-1.39, P = 0.11). When individual components of the composite endpoint were evaluated, 30-month risk of events in AF+ patients was significantly higher. Thirty-month risk of all-cause death was significantly higher in AF+ patients: 18.1% vs 11.1% (HR: 1.62, 95% CI: 1.30-2.02, P < 0.001). There was no significant interaction with randomized treatment and AF for the primary endpoint. Among medically managed high-risk ACS patients receiving DAPT, AF was associated with higher unadjusted risks of ischemic and bleeding outcomes that were similar by treatment group.

Aspirin and the risk of cardiovascular events in atherosclerosis patients with and without prior ischemic events

“…For the purpose of the current analysis, aspirin use was updated at each clinic visit and considered as a time‐varying covariate. Patients using adenosine diphosphate receptor antagonists or anticoagulants at baseline were excluded from the analysis . Patients were categorized into 2 groups: prior ischemic event (defined as history of unstable angina, MI, transient ischemic attack [TIA], or stroke, irrespective of the timing of the event) and stable atherosclerosis, but no prior ischemic event (defined as stable angina requiring medication; history of percutaneous coronary intervention or coronary artery bypass grafting; ≥1 carotid plaque or asymptomatic carotid stenosis ≥70%, history of carotid angioplasty, stent, or surgery; ankle brachial index <0.9 or lower extremity angioplasty, stent, surgery, or amputation).…”