Dual Antithrombotic Therapy with Clopidogrel and Novel Oral Anticoagulants in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Real-world Study

Abstract

IntroductionFor patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), proper antithrombotic therapy is equivocal. Current guidelines recommend triple therapy, which carries a high risk of bleeding. Recent large trials suggest that dual therapy (DT) with novel oral anticoagulant (NOAC) plus P2Y12 inhibitor can be an appropriate alternative, but real-world data for this alternative are scarce and the optimal duration of DT has not yet been established.MethodsThis analysis was performed in a single-center prospective cohort. We investigated 216 PCI patients with indication for anticoagulation due to AF. After PCI patients received DT with reduced doses NOAC plus P2Y12 inhibitor for 6 months, which was followed by standard dose NOAC monotherapy. Efficacy endpoints were defined as cardiac death, myocardial infarction (MI), stent thrombosis (ST), and stroke. Safety endpoints were bleeding events as defined by Bleeding Academic Consortium (BARC).ResultsBaseline characteristics of our study population were described by a CHA2DS2-VASc score of greater than 4 and a HAS-BLED score of greater than 3. After a mean follow-up of 18.7 months, efficacy events occurred in 12 patients (5.6%). We observed three (1.4%) cardiac deaths, two (0.9%) MIs, six (2.8%) strokes, and one (0.5%) definite ST. After switching from DT to NOAC monotherapy after 6.3 ± 1.7 months, there was no rebound of ischemic events. Bleeding events occurred in 34 patients (15.7%) mainly under DT, while bleeding was less during NOAC monotherapy.ConclusionsIn this long-term study of high-risk and real-world AF-patients with PCI, DT with NOAC and P2Y12 inhibitor (6 months) followed by NOAC monotherapy was safe and effective.

Clinical features and posttreatment monitoring of dogs administered rivaroxaban (2018–2020): 19 cases

“…In the current study, 58% of the dogs in this study were coadministered rivaroxaban with clopidogrel. Dual antithrombotic therapy, combining rivaroxaban and clopidogrel, has shown benefit for human patients with acute coronary syndromes, atrial fibrillation, and ischemic stroke 33,34 . Consensus veterinary guidelines suggest dual therapy may be considered for the prevention of venous or arterial thrombosis in high‐risk patient populations such as those with immune‐mediated hemolytic anemia or protein‐losing nephropathy 5 .…”

“…Dual antithrombotic therapy, combining rivaroxaban and clopidogrel, has shown benefit for human patients with acute coronary syndromes, atrial fibrillation, and ischemic stroke. 33,34 Consensus veterinary guidelines suggest dual therapy may be considered for the prevention of venous or arterial thrombosis in high-risk patient populations such as those with immune-mediated hemolytic anemia or protein-losing nephropathy. 5 However, an increased risk of bleeding has been noted in people receiving both platelet inhibitors and anticoagulants.…”

“…5 However, an increased risk of bleeding has been noted in people receiving both platelet inhibitors and anticoagulants. 33,34 Consequently, the risk of thrombosis must be balanced with bleeding risk in canine populations also. Antiplatelet agents are typically recommended for arterial thrombosis, given that arterial clots are platelet rich.…”

“…Consensus veterinary guidelines suggest dual therapy may be considered for the prevention of venous or arterial thrombosis in high‐risk patient populations such as those with immune‐mediated hemolytic anemia or protein‐losing nephropathy 5 . However, an increased risk of bleeding has been noted in people receiving both platelet inhibitors and anticoagulants 33,34 . Consequently, the risk of thrombosis must be balanced with bleeding risk in canine populations also.…”

Dual antithrombotic therapy and gastroprotection in atrial fibrillation: an observational primary care study

“…The risk factors associated with DAT in our study are consistent with previous reports. [19][20][21][22] Amongst AF patients on DAT, 81.7% (340/416) had co-existent CVD (IHD, stroke, TIA). There were 76 patients (18.3%) who were on DAT, but without documented CVD; we noted that these individuals were significantly less likely to receive PPI/H2RA than those with record of CVD.…”