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First published online on July 18, 2008
Chest, doi:10.1378/chest.08-0350
A more recent version of this article appeared on September 1, 2008
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Increased major bleeding complications related to triple antithrombotic therapy usage in patients with atrial fibrillation undergoing

Sergio Manzano-Fernández, MD1; Francisco J. Pastor, MD1; Francisco Marín, MD, PhD1; Francisco Cambronero, MD1; Cesar Caro, MD1; Domingo A. Pascual-Figal, MD, PhD1; Iris P. Garrido, MD1; Eduardo Pinar, MD, PhD1; Mariano Valdés, MD, PhD, Professor1 and Gregory Y.H Lip, MD, Professor2

1Department of Cardiology. University Hospital Virgen de la Arrixaca. Murcia, (Spain) 2University Department of Medicine. City Hospital. Birmingham B18 7QH. UK

g.y.h.lip{at}bham.ac.uk

Abstract

BackgroundThe 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 treated with oral anticoagulation (OAC) undergoing PCI-S.

MethodsWe studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple antithrombotic therapy (TT, which included aspirin, clopidogrel and coumadin) against other regimes (non-TT) after PCI-S. The primary endpoint was defined as the occurrence of major bleeding complications which were defined as "early major bleeding" (EMB, ≤48hours) or "late major bleeding" (LMB, >48hours). Clinical follow up was performed and complications were recorded.

ResultsWe studied 104 patients (mean age 72±8 years, 70% men), where TT was used in 51 (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 IIb/IIIa inhibitor use (HR 13.5, 95%CI 1.7-108.3; p=0.014) and PCI-S of 3 vessels or left main artery disease (HR 7.9, 95%CI 1.6-39.2; p=0.01) were independent predictors for EMB. TT use (HR7.1 95%CI 1.5-32.4, p=0.012), the occurrence of EMB (HR6.7 95%CI 1.8-25.3, p=0.005) and baseline anaemia (HR 3.8 95%CI 1.2-12.5, 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).

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

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






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