“…Previously, it has been reported that dual/triple therapy by adding an OAC decreases the risk of stroke. 16 Despite this stroke risk, most AF patients admitted with MI were discharged without any OAC therapy. Many trials have focused on finding the sweet spot between stroke, stent thrombosis, and major bleeding risk and compared triple and dual therapy strategies with different duration and different regimens.…”
Aim: The prevalence of atrial fibrillation (AF) in patients
with myocardial infarction (MI) ranges widely and has been reported to
be as high as 21%. However, the demographic, clinical, and angiographic
characteristics of AF patients with de novo MI is unclear. The aim of
this study was to investigate the prevalence of patients presenting with
de novo MI with AF. Methods: The study was performed as a sub-study of
the MINOCA-TR (Myocardial Infarction with Non-obstructive Coronary
Arteries in Turkish Population) Registry, a multicenter,
cross-sectional, observational, all-comer registry. MI patients without
a known history of stable coronary artery disease and/or prior coronary
revascularization were enrolled in the study. Patients were divided into
AF and Non-AF groups according to their presenting cardiac rhythm.
Results: A total of 1793 patients were screened and 1626 were included
in the study. Mean age was 61.5 (12.5) years. 70.7% of patients were
men. Prevalence of AF was 3.1% (51 patients). AF patients were older
[73.4 (9.4) vs. 61.0 (12.4) years, p<0.001] than non-AF
patients. The proportion of women to men in the AF group was also higher
than in the non-AF group (43.1% vs. 28.7%, p=0.027). Dramatically, the
minority of patients were previously diagnosed with AF (14 patients,
27.4%) and only 1 out of every 5 AF patients (10 patients, 19.6%) was
using oral anticoagulants (OAC). Conclusions: AF prevalence in patients
presenting with de novo MI was lower than reported in previous studies.
The majority of AF patients did not have any knowledge of their
arrhythmia and were not undergoing OAC therapy at admission, emphasizing
the vital role of successful diagnostic strategies, patient education,
and implementations for guideline adaptation.
“…Previously, it has been reported that dual/triple therapy by adding an OAC decreases the risk of stroke. 16 Despite this stroke risk, most AF patients admitted with MI were discharged without any OAC therapy. Many trials have focused on finding the sweet spot between stroke, stent thrombosis, and major bleeding risk and compared triple and dual therapy strategies with different duration and different regimens.…”
Aim: The prevalence of atrial fibrillation (AF) in patients
with myocardial infarction (MI) ranges widely and has been reported to
be as high as 21%. However, the demographic, clinical, and angiographic
characteristics of AF patients with de novo MI is unclear. The aim of
this study was to investigate the prevalence of patients presenting with
de novo MI with AF. Methods: The study was performed as a sub-study of
the MINOCA-TR (Myocardial Infarction with Non-obstructive Coronary
Arteries in Turkish Population) Registry, a multicenter,
cross-sectional, observational, all-comer registry. MI patients without
a known history of stable coronary artery disease and/or prior coronary
revascularization were enrolled in the study. Patients were divided into
AF and Non-AF groups according to their presenting cardiac rhythm.
Results: A total of 1793 patients were screened and 1626 were included
in the study. Mean age was 61.5 (12.5) years. 70.7% of patients were
men. Prevalence of AF was 3.1% (51 patients). AF patients were older
[73.4 (9.4) vs. 61.0 (12.4) years, p<0.001] than non-AF
patients. The proportion of women to men in the AF group was also higher
than in the non-AF group (43.1% vs. 28.7%, p=0.027). Dramatically, the
minority of patients were previously diagnosed with AF (14 patients,
27.4%) and only 1 out of every 5 AF patients (10 patients, 19.6%) was
using oral anticoagulants (OAC). Conclusions: AF prevalence in patients
presenting with de novo MI was lower than reported in previous studies.
The majority of AF patients did not have any knowledge of their
arrhythmia and were not undergoing OAC therapy at admission, emphasizing
the vital role of successful diagnostic strategies, patient education,
and implementations for guideline adaptation.
“…The accumulating evidence of antithrombotic therapy following PCI in AF patients has been reflected in the guidelines for atrial fibrillation, which resulted in a significant shift from the TAT strategy toward DAT over time (Fig. 4 ) [ 28 ]. Before the publication of the WOEST (2013) and ISAR-TRIPLE (2015) trials, clinical guidelines suggested that these patients should be on TAT (warfarin and DAPT) following PCI.…”
Section: Safety Of Tat In Patients With Af Following Des/pcimentioning
confidence: 99%
“… Fig. 4 Triple therapy: A review of antithrombotic treatment for patients with atrial fibrillation undergoing percutaneous coronary intervention ; this diagram shows the history of guidelines and how the use of TAT is becoming less endorsed [ 28 ]. DOI: 10.1016/j.jjcc.2018.09.001 Fig.…”
Section: Safety Of Tat In Patients With Af Following Des/pcimentioning
Background
Optimal antithrombotic therapy depicts a challenge to clinicians treating atrial fibrillation (AF) patients who are undergoing percutaneous coronary intervention (PCI). Theoretically, these patients would require a combination therapy of oral anticoagulant and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, known as triple antithrombotic therapy (TAT). However, TAT is known to carry a significant risk of bleeding. The purpose of the present paper is to provide a focused review of the evidence about the safety of TAT as well as to address contemporary directions regarding antithrombotic therapy following PCI in patients with AF who received a drug-eluting stent.
Main body
Novel oral anticoagulant studies consistently demonstrated a better safety profile when compared to Vitamin K antagonist (warfarin), especially in AF patients who have other indications of DAPT after PCI. Evidence from several studies showed that the use of TAT in AF patients undergoing stent implantation or PCI has no significant clinical benefit with more risk of major bleeding when compared to DAT. Therefore, the current recommendations for AF have taken into account the mounting evidence of antithrombotic treatment after PCI in AF patients, which has caused a major shift away from the TAT strategy toward DAT over time.
Conclusions
Cardiologists face challenges in determining the best antithrombotic treatment for AF patients after PCI with DES implantation. Growing data suggest that TAT is associated with considerable bleeding and worse safety, without significant effectiveness. Hence, TAT is strictly applied for individuals with significant thrombotic risk and low bleeding risk, and for a limited duration. This paper highlights the safety concerns of TAT and current trends in antithrombotic therapy after PCI in patients with AF and DES.
“…Although dual antiplatelet therapy (DAPT) with aspirin and a P2Y 12 inhibitor is effective in reducing cardiac events and stent thrombosis after PCI [ 2 , 3 ], oral anticoagulation is the therapy of choice for the prevention of stroke and systemic embolism in patients with AF [ 4 ]. However, triple antithrombotic therapy (TAT) is known to be associated with an excess in major bleeding, ranging from 4 to 12% within the first year of treatment [ 5 , 6 ] and hemorrhagic risk is 4 times higher than that observed with aspirin alone [ 7 ]. The occurrence of a bleeding complication is known to affect the prognosis of the patients, as it determines the discontinuation of all antithrombotic drugs [ 8 ].…”
High platelet reactivity (HPR) on clopidogrel is an established thrombotic risk factor after percutaneous coronary intervention (PCI). The introduction of more potent antiplatelet drugs has partially surpassed this issue. However, in the setting of concomitant atrial fibrillation (AF) and PCI clopidogrel is still the most adopted P2Y12 inhibitor. In the present study all consecutive patients with history of AF discharged from our cardiology ward with dual (DAT) or triple (TAT) antithrombotic therapy after a PCI from April 2018 to March 2021 were enrolled in an observational registry. For all subjects, blood serum samples were collected and tested for platelet reactivity by arachidonic acid and ADP (VerifyNow system) and genotyping of the CYP2C19*2 loss-of-function polymorphism. We recorded at 3 and 12-months follow-up: (1) major adverse cardiac and cerebrovascular events (MACCE), (2) major hemorrhagic or clinically relevant non-major bleeding and (3) all-cause mortality. A total of 147 patients were included (91, 62% on TAT). In 93.4% of patients, clopidogrel was chosen as P2Y12 inhibitor. P2Y12 dependent HPR resulted an independent predictor of MACCE both at 3 and 12 months (HR 2.93, 95% C.I. 1.03 to 7.56, p = 0.027 and HR 1.67, 95% C.I. 1.20 to 2.34, p = 0.003, respectively). At 3-months follow-up the presence of CYP2C19*2 polymorphism was independently associated with MACCE (HR 5.21, 95% C.I. 1.03 to 26.28, p = 0.045). In conclusion, in a real-world unselected population on TAT or DAT, the entity of platelet inhibition on P2Y12 inhibitor is a potent predictor of thrombotic risk, suggesting the clinical utility of this laboratory evaluation for a tailored antithrombotic therapy in this high-risk clinical scenario.
Graphical abstract
The present analysis was performed in patients with AF undergoing PCI on dual or triple antithrombotic therapy. At 1 year follow-up MACCE incidence was consistent, and it was not different in different antithrombotic pattern groups. P2Y12 dependent HPR was a potent independent predictor of MACCE both at 3- and 12-months follow-up. In the first 3 months after stenting the carriage of CYP2C19*2 allele was similarly associated with MACCE. Abbreviation: DAT, dual antithrombotic therapy; HPR, high platelet reactivity; MACCE, major adverse cardiac and cerebrovascular events; PRU, P2Y12 reactive unit; TAT, triple antithrombotic therapy. Created with BioRender.com.
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