Should We Recommend Oral Anticoagulation Therapy in Patients With Atrial Fibrillation Undergoing Coronary Artery Stenting With a High HAS-BLED Bleeding Risk Score?

Abstract

Background— Recent European guidelines for the management of atrial fibrillation recommend oral anticoagulation (OAC) in patients with CHA 2 DS 2 -VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes, history of previous stroke, vascular disease, age 65–74 years, and sex category [female]) ≥1. The HAS-BLED score (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly [>65 years], Drugs/alcohol concomitantly) has been suggested to assess bleeding risk in patients with atrial fibrillation (score ≥3 indicates high risk of bleeding). Despite the guidelines, this approach has never been tested in a cohort of patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation. Methods and Results— We studied 590 consecutive patients with atrial fibrillation undergoing percutaneous coronary intervention/stenting and CHA 2 DS 2 -VASC score >1 (ie, OAC recommended). We compared patients with low-intermediate bleeding risk (HAS-BLED 0–2) and high risk (HAS-BLED ≥3), the relation between CHA 2 DS 2 -VASC and HAS-BLED, and the benefit and risks of the use of OAC in patients with high bleeding risk. The development of any bleeding episode, thromboembolism, mortality, cardiac events, and the composite major adverse cardiac events (ie, death, acute myocardial infarction, and/or target lesion revascularization) end point was recorded as well as the composite major adverse events (ie, major adverse cardiac events, major bleeding, or thromboembolism) end point at 1-year follow-up. Of the study cohort, 420 (71%) had a HAS-BLED score ≥3, and patients who were on OAC at discharge had lower mortality rate (9.3% versus 20.1%; P <0.01) and major adverse cardiac events (13.0% versus 26.4%; P <0.01) but with a similar major adverse event (20.5% versus 27.6%; P =0.11) and higher major bleeding rate (11.8% versus 4.0%; P <0.01). In a Cox multivariable analysis in patients with HAS-BLED ≥3, predictors of increased death were chronic renal failure and heart failure (both P <0.05), whereas OAC at discharge was associated with a reduced death rate ( P <0.01). Predictors of major bleeding were chronic renal failure and the use of drug-eluting stents (both P <0.05). Conclusions— Most patients with atrial fibrillation undergoing percutaneous coronary intervention/stenting have a high risk for major bleeding (HAS-BLED score ≥3). Even in these patients, OAC improves prognosis in these patients (reduced mortality and major adverse cardiac events) with an increase in major bleeding.

Effects of Triple Therapy in Patients With Non-Valvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention Regarding Thromboembolic Risk Stratification

“…Therefore, DAPT was preferred over a single antiplatelet agent, likely because 73% of patients had an ACS as index event, in accordance with other studies. 24, 39 In agreement with our results, both Tomita et al 43 and Okumura et al 44 recently reported that patients with AF and modified CHA2DS2-VASc score=1 (registry did not include peripheral artery disease or aortic plaque) had a truly low risk of thromboembolism (0.86%), even when female sex was excluded (1.0%), suggesting that the use of anticoagulation must be avoided in this subgroup of patients. 43, 44 On the other hand, Abe et al 45 found no significant sex difference in the annual incidence of thromboembolism (1.2% for women, 1.6% for men; odds ratio 0.72, 95% CI 0.28-1.62; P=0.44).…”

“…In agreement with other authors, we also found a strong correlation between stroke and bleeding risk scores, with patients with CHA2D2S-VASc ≥2 being those with the highest bleeding risk, defined as HAS-BLED ≥3. 39 In contrast, we found no association between CHA2D2S-VASc score and MACE or MAE. Therefore, decisions concerning the optimal antithrombotic management of patients with AF undergoing DAPT might be a safe strategy after coronary stenting in patients with AF and low thromboembolic risk.…”

Meta-Analysis of CHADS2 versus CHA2DS2-VASc for Predicting Stroke and Thromboembolism in Atrial Fibrillation Patients Independent of Anticoagulation

“…Our data thus extend the available evidence base of the CHA 2 DS 2 -VASc method in predicting stroke, TE, or both in patients with AF, and show that the CHA 2 DS 2 -VASc score enables the identification of a larger number of AF patients for whom oral anticoagulation would be recommended. 24 Our meta-analysis also reveals a powerful predictive value of both the CHADS 2 and CHA 2 DS 2 -VASc for the highest-risk stratum of patients, independent of anticoagulation. Our results indicate that cardiovascular events might also occur in anticoagulated AF patients and reveal a stepwise increase in stroke or TE events upon increasing scores across risk strata in anticoagulated patients.…”

Anti-thromboembolic strategies in atrial fibrillation

“…In another study, anticoagulated (with VKAs) AF-patient who needed PCI-SI were grouped according to their bleeding risk which was assessed by the HAS-BLED score [75]. More than 70% of patients had a score of 3 or higher.…”