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Increased Major Bleeding Complications Related to Triple Antithrombotic Therapy Usage in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Artery Stenting

*From the Department of Cardiology (Drs. Manzano-Fernández, Pastor, Marín, Cambronero, Caro, Pascual-Figal, Garrido, Pinar, and Valdés), University Hospital Virgen de la Arrixaca, Murcia, Spain; and University Department of Medicine (Dr. Lip), City Hospital, Birmingham, UK.

Correspondence to: Gregory Y. H. Lip, MD, University Department of Medicine, City Hospital, Birmingham B18 7QH, UK; e-mail: g.y.h.lip{at}bham.ac.uk

Abstract

Background:The optimal antithrombotic therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of antithrombotic therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S.

Methods:We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple antithrombotic therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [ 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded.

Results:We studied 104 patients (mean age ± SD, 72 ± 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p = 0.006) but not of EMB (5.8% vs non-TT, 11.3%; p = 0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p = 0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p = 0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p = 0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p = 0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p = 0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p = 0.53).

Conclusion:A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.

Key Words: acute coronary syndrome • anticoagulation • antiplatelet • atrial fibrillation • percutaneous coronary intervention

Abbreviations: A+C, aspirin and clopidogrel • AF, atrial fibrillation • BMS, bare metal stent • CI, confidence interval • DES, drug-eluting stent • EMB, early major bleeding • GP, glycoprotein • HR, hazard ratio • INR, international normalized ratio • IQR, interquartile range • LMB, late major bleeding • MACE, major adverse cardiovascular event • OAC, oral anticoagulation • PCI, percutaneous coronary intervention • PCI-S, percutaneous coronary intervention with stent implantation • TT, triple antithrombotic therapy