Triple therapy not associated with fewer ischemic events vs. DAPT in patients with AF receiving DES

Researchers found that triple therapy was not associated with decreased ischemic events but was linked to increased bleeding risk vs. dual antiplatelet therapy in patients with atrial fibrillation undergoing PCI with a drug-eluting stent.

AF was common among the real-world patient population and was linked to increased ischemic and bleeding risk, the researchers wrote.

“Until recently, the prevalence and clinical relevance of AF after PCI with DES in a real-world clinical setting is not fully determined, and the optimal antithrombotic therapy for such patients is an emerging clinical problem,” Hyo-In Choi, MD, from the division of cardiology at Asan Medical Center at the University of Ulsan College of Medicine in Seoul, Korea, and colleagues wrote. “The purpose of our study was to determine the prevalence, treatment and long-term clinical impact of AF in unrestricted population who underwent PCI with DES in a real-world clinical setting and to compare the relative efficacy and safety of the DAPT and triple therapy in patients with AF using a large cohort of PCI patients receiving DES with long-term follow-up data.”

Researchers evaluated the overall prevalence and clinical impact of AF in 10,027 consecutive patients who underwent DES implantation for stable angina or ACS at a single center between 2003 and 2011.

Choi and colleagues also compared the safety and efficacy of DAPT (aspirin plus clopidogrel) and triple therapy (DAPT plus warfarin) for use in patients with AF.

The primary outcome was a composite of CV death, MI or stroke.

Secondary outcomes of the study were all-cause mortality, MI, stroke, stent thrombosis, repeat revascularization, and major and nonmajor bleeding events, the researchers wrote.

Of the 10,027 patients initially observed, 711 (7.1%) patients had an AF diagnosis at the index PCI hospitalization.

Patients with AF were older, had more comorbid conditions, and typically had a history of stroke.

At discharge, 629 patients (88.4%) with AF received DAPT vs. 75 patients (10.5%) who received triple therapy, according to the researchers.

AF confers high risk

Patients with AF had a much higher rate of primary outcome after PCI during the 6-year follow-up period vs. those without AF (22.1% vs. 8%; P < .001), which was also true for major bleeding (4.5% vs. 1.5%; P < .001).

Researchers found that the presence of AF was linked to a higher risk for primary outcome (HR = 2.33; 95% CI, 1.95-2.79) and major bleeding (HR = 2.01; 95% CI, 1.32-3.06) after multivariable adjustment.

In those with AF, adjusted risk for the primary outcome was similar between the DAPT group and the triple therapy group (HR = 1.01; 95% CI, 0.6-1.69), but risk for hemorrhagic stroke (HR = 7.73; 95% CI, 2.14-27.91) and major bleeding (HR = 4.48; 95% CI, 1.81-11.08) were significantly higher with triple therapy.

Questionable viewpoint

In a related editorial, Davide Capodanno, MD, PhD, from the Ferrarotto Hospital and University of Catania in Italy, and Dominick J. Angiolillo, MD, PhD, from the University of Florida College of Medicine in Jacksonville, and a member of the Cardiology Today’s Intervention Editorial Board, wrote, “Stereotyping AF patients with DES as being more exposed to the risk of bleeding with [oral anticoagulation] than exposed to the risk of stroke without [oral anticoagulation] is a questionable viewpoint.” According to Capodanno and Angiolillo, fear of bleeding still plays a role in preventing physicians from prescribing evidence-based therapies regardless of their proven benefits.

“The good news is that we have entered an era of increased perceived and tangible safety that applies to both [nonvitamin K antagonist oral anticoagulants] and newer DES,” they wrote. “This implies less bleeding with [oral anticoagulation] in combination with antiplatelet therapy and a shift toward safer and shorter DAPT regimens with the use of selected DES for patients in need.” – by Dave Quaile

Disclosure: The researchers report no relevant financial disclosures. Angiolillo reports receiving support from various medical and device companies. Capodanno reports receiving consultant fees and honoraria from AstraZeneca, Bayer, Daiichi Sankyo, Eli Lilly and The Medicines Company.