The management of patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation

Abstract

Current recommendations on the management of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention with stent (PCI-S) essentially derive from small, single-center, retrospective datasets. To obtain larger and better quality data, we carried out the prospective, multicenter Atrial Fibrillation undergoing Coronary Artery Stenting (AFCAS) study. Therefore, consecutive patients with history of or ongoing AF undergoing PCI-S were enrolled, and occurrence of adverse ischemic and bleeding events recorded during 12 months follow-up. In this article, we report the in-hospital observations. Out of the 963 patients, in the majority of cases (49.1%) AF was permanent. The associated risk of stroke, as defined by a CHADS2 -score ≥2, was in 70% of patients moderate to high. Upon enrollment in the registry, 69.3% of patients were on VKA therapy. Overall occurrence of in-hospital major adverse cardiac events was 4.5% (cardiovascular death 1.9%, urgent revascularization in 1.5%, and stroke/arterial thromboembolism in 0.6%). Bleeding complications occurred in 7.1% of patients, being severe in 2.5%. In a logistic regression analysis, no risk factor was independently associated with bleeding events, whereas Clopidogrel treatment decreased and female gender/treatment with gpIIb/IIIa-antagonists, respectively increased the risk for the combined ischemic endpoint. The majority of AF patients undergoing PCI-S are at high stroke risk, and therefore VKA treatment should not be withdrawn and combined anticoagulant and antiplatelet treatment is warranted. Current management appears largely in accordance with current recommendations, whereby accounting for the limited occurrence of in-hospital adverse ischemic and bleeding events.

Anticoagulant and Antiplatelet Prescribing Patterns for Patients with Atrial Fibrillation after Percutaneous Coronary Intervention

“…This rate is much lower than those reported in other recently published observational studies, which ranged from 64% to 72%. 12,13 Schlitt and others 12 reported that the most common antithrombotic regimen on discharge among 963 patients with atrial fibrillation who underwent percutaneous coronary intervention was TAT (71.8%), containing warfarin (60.9% of all patients) or low-molecular-weight heparin 1 (1) CHADS2 = congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke; HASBLED = hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol. *Some patients had more than one condition.…”

Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

“…This is also in line with registry data showing that patients with AF undergoing PCI have a CHADS 2 score ≥2 in ≈70% of cases, so that OAC treatment should not be withdrawn even when combined anticoagulant and antiplatelet treatment is warranted. 132 Indeed, there are many other bleeding scores. 120,127,133 The discriminatory value of these scores after PCI is uncertain.…”

Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

“…This is also in line with registry data showing that patients with AF undergoing PCI have a CHADS 2 score ≥2 in ≈70% of cases, so that OAC treatment should not be withdrawn even when combined anticoagulant and antiplatelet treatment is warranted. 72 …”