February 19, 2008 - A regimen of aspirin, clopidogrel and coumadin started at discharge decreased mortality and major adverse cardiac events (MACE) while keeping bleeding to acceptable levels in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with stent placement, reports a study in the February 26, 2008 issue of the Journal of the American College of Cardiology.
The researchers in the study, led by Gregory Y.H. Lip, MD, of City Hospital (Birmingham, UK), advise not to use drug-eluting stents (DES) in patients with AF requiring anticoagulation because of the increased bleeding risk that would accompany the addition of prolonged dual antiplatelet therapy.
The study included 426 elderly patients (mean age 71.5 years) with AF undergoing PCI with stenting at 2 hospitals in Spain between 2001 and 2006. Half of the patients were discharged with triple therapy (coumadin, aspirin, and clopidogrel). After 2 years of follow-up, patients who were not on coumadin at discharge had significantly higher rates of mortality, MACE, and other adverse events as compared with patients who were on a regimen including coumadin when they left the hospital.
In the study, patients given DES (n=174, 40.1% of cohort) had a higher rate of stent thrombosis (2.8% vs. 0%, P=0.034). This fact, combined with the necessity for prolonged dual antiplatelet therapy compared with bare-metal stents (BMS), convinced the study authors to recommend against the use of DES in anti-coagulated AF patients.
The study authors noted that deciding on the proper anticoagulant/antiplatelet regimen in AF patients undergoing PCI amounts to a balancing act in each individual, in which the risk of bleeding (increased in triple therapy) must be weighed against the risk of stroke, stent thrombosis, and other ischemic events (increased with AF and stent implantation).
The study concluded: “in those patients with AF treated with PCI/stents who have a low risk of bleeding complications, a triple-therapy regimen should be the elective antithrombotic drug treatment approach.”
In an editorial accompanying the study, Steven Francescone, M.D., and Jonathan L. Halperin, M.D., both of the Mount Sinai Medical Center (New York, NY), agreed that “for those at low risk of serious bleeding, treatment with triple therapy may be the best option.”
In addition, they wrote that, “BMS may be preferable to DES in patients with AF who have risk factors for thromboembolism requiring chronic anticoagulation to reduce the need for prolonged combination therapy.”
For more information: www.acc.org