Optimal long-term antithrombotic treatment of patients with stable coronary artery disease and atrial fibrillation : - mai 2018

Par Samuel Cohen - Mise en ligne le 30 août 2018

Mots clefs : Stable coronary artery disease /Atrial fibrillation/ Antithrombotic treatment/ Bleeding Ischaemic event

International Journal of Cardiology

Q. Fischer, J.L. Georges. Le Feuvre, A. Sharma, N. Hammoudi, E. Berman, S. Cohen, I. Jolivet, J. Silvain , G. Helft

Background: The optimal long-term antithrombotic treatment of patients with stable coronary artery disease (CAD) and atrial fibrillation (AF) is a challenge in daily practice. We sought to determine the prevalence of hem- orrhagic complications and ischaemic events depending on antithrombotic strategy in patients with stable CAD and AF.

Methods: The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of cardiovascular mortality, myocardial infarction and ischaemic stroke. The subsequent risks of MACCE and clinically significant bleedings requiring hospitalisation (major safety outcome) were analyzed in a propensity score–matched analysis by adjusted Cox regression models.

Results: Six hundred and six patients with high thrombotic and bleeding risks (mean age 73.4 ± 9.8 years, 25.2% female, CHA2DS2-VASc score:4.7 ± 1.5, and HAS-BLED score:3.1 ± 1.0) were included, and 127 propensity- matched pairs were analyzed. At inclusion, 172 patients (28.4%) were on oral anticoagulation (OAC) alone (75.6% on VKA and 24.4% on DOAC) and 434 patients (71.6%) on OAC + single antiplatelet therapy (SAPT) (71.9% on VKA and 28.1% on DOAC). At 5-year follow-up, MACCE rate did not significantly differ in both groups (30.9% in OAC + SAPT vs. 26.8% in OAC alone; adjusted HR 1.1 [0.8–1.5], p = 0.58), but clinically significant bleedings (28.3% vs. 18.5%; adjusted HR 1.8 [1.2–2.8], p = 0.005) and total deaths (29.5% vs. 20.8%; adjusted HR 1.4 [95% CI 1.0–2.2], p = 0.049) were higher in patients with OAC + SAPT than in patients with OAC alone.

Conclusions: In patients with stable CAD and AF, the addition of antiplatelet therapy to VKA or DOAC therapy was independently associated with a higher risk of bleeding and overall mortality, without significant reduction in cardiac and cerebral ischaemic events.

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