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FOCUS ISSUE: ATRIAL FIBRILLATION: CLINICAL RESEARCH: ATRIAL FIBRILLATION AND EMBOLISM

Anticoagulant and Antiplatelet Therapy Use in 426 Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention and Stent Implantation

Implications for Bleeding Risk and Prognosis

Juan M. Ruiz-Nodar, MD, PhD^_*, Francisco Marín, MD, PhD^,, José Antonio Hurtado, MD^,, José Valencia, MD, PhD^_*, Eduardo Pinar, MD, PhD^,, Javier Pineda, MD, PhD^_*, Juan Ramón Gimeno, MD, PhD^,, Francisco Sogorb, MD, PhD^_*, Mariano Valdés, MD, PhD and Gregory Y.H. Lip, MD, FACC, FESC^,_*

^_* Department of Cardiology, Hospital General Universitario de Alicante, Alicante, Spain
Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
Red de Investigación Cardiovascular RECAVA, Instituto Salud Carlos III, Madrid, Spain
University Department of Medicine, City Hospital, Birmingham, United Kingdom.

Manuscript received August 20, 2007; revised manuscript received October 29, 2007, accepted November 20, 2007.

^_* Reprint requests and correspondence: Dr. Gregory Y. H. Lip, University Department of Medicine, City Hospital, Birmingham B18 7QH, United Kingdom. (Email: g.y.h.lip{at}bham.ac.uk).

Objectives: This study was designed to review outcomes in relation to antithrombotic therapy management strategies for patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) with stenting.

Background: There is limited evidence on the optimal antithrombotic therapy management strategies for patients with AF who undergo PCI with stenting.

Methods: We reviewed 426 patients (70.9% men, mean age 71.5 ± 8.5 years) with AF undergoing PCI with stenting between 2001 and 2006. We recorded clinical and demographic characteristics of the patients, stroke risk factors, and antithrombotic therapy use before PCI and at discharge. Clinical follow-up was performed, and all bleeding episodes, thromboembolism, and major adverse cardiac events (MACE) (i.e., death, acute myocardial infarction, or target lesion revascularization) were recorded.

Results: The most commonly associated comorbidities were hypertension (74.5%), diabetes mellitus (40.2%), chronic renal failure (14.9%), and congestive heart failure (26.7%); 80% of patients had 2 stroke risk factors. Of the drugs prescribed at discharge, aspirin plus clopidogrel were used in 174 patients (40.8%), whereas 213 patients (50%) were discharged with triple therapy (coumarins, aspirin, and clopidogrel). Complete follow-up was achieved in 87.5% (median 594 days; range 0 to 2,190). The incidence of adverse events was high (36.6%), with major bleeding in 12.3%, thromboembolic events in 4.2%, and MACE in 32.3%. All-cause mortality was high (22.6%). In a multivariate analysis, non-anticoagulation with coumarins increased mortality (17.8% vs. 27.8%; hazard ratio [HR] = 3.43; 95% confidence interval [CI] 1.61 to 7.54; p = 0.002) and MACE (26.5% vs. 38.7%; HR = 4.9; 95% CI 2.17 to 11.1; p < 0.01) In a Cox-regression analysis, non-anticoagulation (p < 0.01) and age (p = 0.02) were independent predictors of MACE.

Conclusions: Patients with AF undergoing PCI with stenting represent a high-risk population because of age, comorbidities, and presence of stroke risk factors. These patients have a high mortality and MACE rate, which is reduced by anticoagulation therapy.

Abbreviations and Acronyms   ACS = acute coronary syndrome   AF = atrial fibrillation   DES = drug-eluting stent(s)   MACE = major adverse cardiac events   MAE = major adverse events   PCI = percutaneous coronary intervention

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