scholarly journals Antithrombotic Therapy in Patients with Atrial Fibrillation and Acute Coronary Syndrome

2020 ◽  
Vol 9 (7) ◽  
pp. 2020
Author(s):  
Wilbert Bor ◽  
Diana A. Gorog
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Combination Therapy ◽  
Bleeding Risk ◽  
Careful Consideration ◽  
P2y12 Inhibitor ◽  
Coronary Syndrome ◽  
Antithrombotic Efficacy ◽  
Selection Of ◽  
Made In

Acute coronary syndrome and atrial fibrillation are both common and can occur in the same patient. Combination therapy with dual antiplatelet therapy and oral anticoagulation increases risk of bleeding. Where the two conditions coexist, careful consideration is needed to determine the optimal antithrombotic treatment to reduce the risks of future ischaemic events associated with both conditions. Choices can be made in intraprocedural anticoagulation, type and dosing of oral anticoagulant, duration of combination therapy, and selection of P2Y12 inhibitor including genetic testing. This review article provides an overview of the available evidence to support clinicians in finding the delicate balance between antithrombotic efficacy and bleeding risk in patients with acute coronary syndrome and atrial fibrillation.

scholarly journals New Antithrombotic Drugs in Acute Coronary Syndrome

2020 ◽  
Vol 9 (7) ◽  
pp. 2059
Author(s):  
Bastiaan Zwart ◽  
William A. E. Parker ◽  
Robert F. Storey
Keyword(s):  
Acute Coronary Syndrome ◽  
Bleeding Risk ◽  
Antithrombotic Drugs ◽  
P2y12 Inhibitors ◽  
Coronary Syndrome ◽  
Anticoagulant Drugs ◽  
Antithrombotic Efficacy ◽  
Made In

In recent years, much progress has been made in the field of antithrombotic drugs in acute coronary syndrome (ACS) treatment, as reflected by the introduction of the more potent P2Y12-inhibitors prasugrel and ticagrelor, and novel forms of concomitant anticoagulation, such as fondaparinux and bivalirudin. However, despite substantial improvements in contemporary ACS treatment, there remains residual ischemic risk in this group and hence the need for even more effective antithrombotic drugs, while balancing antithrombotic efficacy against bleeding risk. This review discusses recently introduced and currently developed antiplatelet and anticoagulant drugs in ACS treatment.

Safety and efficacy of antithrombotic therapy according to stroke and bleeding risk in patients with atrial fibrillation and acute coronary syndrome or PCI: insights from AUGUSTUS

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Harskamp ◽  
R.D Lopes ◽  
Z Li ◽  
D Wojdyla ◽  
S.G Goodman ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Bleeding Risk ◽  
Cox Proportional Hazards ◽  
Baseline Risk ◽  
P Value ◽  
Funding Source ◽  
P2y12 Inhibitor ◽  
Risk Of Death ◽  
Coronary Syndrome

Abstract Background The AUGUSTUS trial showed that patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) and/or PCI treated with a P2Y12 inhibitor and apixaban resulted in less bleeding and comparable ischemic events compared with regimens that included a vitamin K antagonist (VKA), aspirin, or both. We assessed the effect of apixaban versus VKA and aspirin versus placebo according to patients' baseline risk of stroke and bleeding. Methods AUGUSTUS randomized 4614 patients in a two-by-two factorial design to open label apixaban or VKA and blinded aspirin or placebo. The primary endpoint was major or clinically relevant nonmajor (CRNM) bleeding over 6 months of follow-up. The effects were assessed stratified by baseline CHA2DS2-VASc and HAS-BLED score using Cox proportional hazards models. Results 4386 patients were included for this analysis. The median age was 71 (64–77) years, 29.4% were female, 81.7% had a CHA2DS2-VASc score≥3, and 66.8% a HAS-BLED score≥3. As shown in the table, rates of bleeding were lower with apixaban (vs VKA) irrespective of baseline bleeding risk (p-value interaction: 0.23). Aspirin (vs placebo) was associated with increased bleeding irrespective of baseline risk (p-value interaction: 0.88). Apixaban use was associated with a lower risk of death or hospitalization without a significant interaction with stroke risk (p-value of interaction=0.53). No differences were found for ischemic outcomes. Conclusion An antithrombotic regimen including a P2Y12 inhibitor and apixaban is associated with less bleeding and hospitalization compared to a regimen with VKA, aspirin, or both with results consistent across CHA2DS2-VASc, and HAS-BLED scores. Our findings support the use of apixaban and a P2Y12 inhibitor without aspirin during the first 6 months for most patients with AF and ACS and/or PCI, regardless of stroke and bleeding risk. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The Augustus trial was sponsored by Bristol-Myers Squibb and Pfizer, Inc

scholarly journals Combination of Oral Anticoagulants and Single Antiplatelets versus Triple Therapy in Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome: Stroke Prevention among Asians

2020 ◽  
Vol 29 (02) ◽  
pp. 088-097
Author(s):  
Anwar Santoso ◽  
Sunu B. Raharjo
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Triple Therapy ◽  
Stroke Prevention ◽  
Thrombus Formation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Nonvalvular Atrial Fibrillation ◽  
Coronary Syndrome

AbstractAtrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)–vascular disease, age 65 to 74 years, sex category (female; CHA2DS2-VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, “triple therapy” comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for “triple therapy” would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.

scholarly journals Clopidogrel as a part of double disaggregant therapy in ACS: a reasonable choice in complex clinical situations

2019 ◽  
pp. 20-29 ◽  
Author(s):  
V. V. Kashtalap ◽  
O. L. Barbarash
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Antiplatelet Therapy ◽  
Clinical Case ◽  
Correct Selection ◽  
Coronary Syndrome ◽  
Hemorrhagic Events ◽  
Register Studies ◽  
Reasonable Choice ◽  
Selection Of

Based on the recommendations of the European Heart Society and the results of clinical and register studies, the article highlights the complex issues that arise when prescribing antiplatelet therapy in patients with acute coronary syndrome, including with concomitant atrial fibrillation (AF); the promising strategies for managing the risk of ischemic and hemorrhagic events are described. Also a clinical case of a patient with acute coronary syndrome and AF is presented, illustrating the objective complexity of correct selection of antiplatelet therapy in such patients.

scholarly journals Incidence of aspirin resistance is higher in patients with acute coronary syndrome and atrial fibrillation than without atrial fibrillation

2020 ◽  
Vol 66 (6) ◽  
pp. 800-805
Author(s):  
Hasan Aydin Baş ◽  
Fatih Aksoy ◽  
Ali Bağcı ◽  
Ercan Varol ◽  
Ahmet Altınbaş
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Prospective Trial ◽  
High Sensitivity ◽  
Bleeding Risk ◽  
Adenosine Diphosphate ◽  
Coronary Intervention ◽  
Inhibitory Effect ◽  
Aspirin Resistance ◽  
Coronary Syndrome

SUMMARY In patients with atrial fibrillation, standard anticoagulation with a vitamin K antagonist plus dual antiplatelet therapy with a P2Y12 inhibitor and aspirin is the standard of care after percutaneous coronary intervention (PCI). While this therapy reduces the risk of thrombosis and stroke, it increases the risk of bleeding. It is unclear whether the antiplatelet effect of aspirin and clopidogrel may worsen atrial fibrillation (AF). OBJECTIVE Thus we aimed to analyze platelet aspirin resistance (AR) and clopidogrel resistance (CR) in acute coronary (ACS) patients based on sinus rhythm (SR) and AF. METHODS In this prospective trial, we included 543 patients (mean age: 62± 12 years; range: 26 - 89 years) who were on aspirin and clopidogrel therapy after the diagnosis of acute coronary syndrome. AR and CR were analyzed by a Multiplate® MP-0120 device by using the method of whole blood aggregometry. RESULTS AF patients had significantly higher age, mean platelet volume, and High-Sensitivity C-Reactive Protein (p< 0.01 for each parameter). Similarly, Arachidonic-acid induced (ASPI) aggregation was higher in AF patients compared to SR patients (666±218 vs. 187±179, p<0.001). Among the ACS patients, significantly more female patients had AF (p<0.001). The incidence of hypertension in the AF group was higher compared to the SR group (p<0.001). However, adenosine diphosphate levels were not at a significant level in the two groups. CONCLUSION Our findings indicate that the platelet inhibitory effect of Aspirin was worse for patients with AF, suggesting that the effectiveness of aspirin may be less in the prophylaxis of thromboembolism and more a bleeding risk.

A randomised study for optimising crossover from ticagrelor to clopidogrel in patients with acute coronary syndrome

2017 ◽  
Vol 117 (02) ◽  
pp. 303-310 ◽  
Author(s):  
Ali Pourdjabbar ◽  
Benjamin Hibbert ◽  
Aun-Yeong Chong ◽  
Michel R. Le May ◽  
Marino Labinaz ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Platelet Reactivity ◽  
Bleeding Risk ◽  
Platelet Inhibition ◽  
Cardiac Events ◽  
P2y12 Inhibitor ◽  
Randomised Study ◽  
Coronary Syndrome ◽  
Adverse Cardiac Events ◽  
Supplementary Material

SummaryTicagrelor has been endorsed by guidelines as the P2Y12 inhibitor of choice in patients with acute coronary syndrome. Clinically, some patients on ticagrelor will require a switch to clopidogrel; however, the optimal strategy and pharmacodynamics effects of switching remain unknown. Patients with an indication to switch were randomly assigned to either a bolus arm (Clopidogrel 600 mg bolus followed by 75 mg daily, n=30) or a no-bolus arm (Clopidogrel 75 mg daily, n=30). Blood samples were collected at baseline, 12, 24, 48, 54, 60 and 72 hours (h) for assessment of platelet reactivity. The primary outcome was P2Y12 reactivity units (PRU) at 72 h. Secondary outcomes included: PRUs at each time point, incidence of high on-treatment platelet reactivity (HPR), major adverse cardiac events (MACE) and TIMI bleeding at 30 days. Serial PRUs increased after switching to clopidogrel in both groups. At 72 h, no difference in PRU was observed (165.8 ± 71.0 vs 184.1 ± 67.7, bolus vs no bolus, respectively, p=0.19). At 48 h the PRUs were significantly lower in the bolus arm (114 ± 73.1 vs 165.1 ± 70.5, respectively; p=0.0076) and at 72 h, there was a significant reduction in incidence of HPR (26.7 % vs 56.7 %, p=0.02). No differences in MACE or TIMI bleeding were observed. Although a bolus strategy was not associated with improved platelet inhibition at 72 h; at 48 h, platelet inhibition was superior with reduced incidence of HPR. Larger studies will be required to determine its clinical significance. Until then, decision for giving a bolus of clopidogrel at the time of a switch may in part be dependent on the indication for switching, especially if there are concerns for bleeding risk.Supplementary Material to this article is available online at www.thrombosis-online.com.

scholarly journals Possibility of using dabigatran in patients with atrial fibrillation and acute coronary syndrome and PCI

2019 ◽  
pp. 30-35
Author(s):  
A. D. Erlich
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Triple Therapy ◽  
Oral Anticoagulants ◽  
Dual Therapy ◽  
Clinical Problem ◽  
Coronary Intervention ◽  
Bleeding Complications ◽  
P2y12 Inhibitor ◽  
Coronary Syndrome

This article is devoted to the problem of combined antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) due to acute coronary syndrome (ACS). Traditionally, these patients require an oral anticoagulant (OAC) to prevent stroke and dual anti-platelet therapy (DAT) to prevent coronary complications. The necessity of combining various antithrombotic drugs, since this greatly increases the risk of bleeding is becoming an increasing relevant clinical problem. The prolonged triple therapy in the form of a combination of OAC and DAT does not bring additional benefit to the patients, but, on the contrary, may be potentially dangerous. Currently, the possibility of using several new oral anticoagulants (NOAC) in patients with AF and ACS/PCI in the form of dual therapy has been proven: combination of OAC and p2Y12 inhibitor. The article focuses on the RE-DUAL PCI study, in which the use of dabigatran at both doses permitted in AF (150 mg twice daily and 110 mg twice daily) in combination with the p2Y12 inhibitor was associated with fewer bleeding complications than during the triple therapy in the form of OAK + DAT.The article presents a clinical case of the possibility of management of a patient with AF and ACS under the modern clinical guidelines, as well as an overview of current guidelines for the use of OAC and DAT in patients with AF undergoing PCI. 

scholarly journals Antithrombotic Management for Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention or With Acute Coronary Syndrome: An Evidence-Based Update

2021 ◽  
Vol 8 ◽  
Author(s):  
Shujuan Zhao ◽  
Xuejiao Hong ◽  
Haixia Cai ◽  
Mingzhou Liu ◽  
Bing Li ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Acute Coronary Syndrome ◽  
Vitamin K ◽  
Coronary Intervention ◽  
Vitamin K Antagonist ◽  
P2y12 Inhibitor ◽  
Coronary Syndrome ◽  
Percutaneous Coronary ◽  
Antithrombotic Management

Combined antithrombotic regimens for atrial fibrillation (AF) patients with coronary artery disease, particularly for those who have acute coronary syndrome (ACS) and/or are undergoing percutaneous coronary intervention (PCI), presents a great challenge in the real-world clinical scenario. Conventionally, a triple antithrombotic therapy (TAT), which consists of combined oral anticoagulant therapy to prevent systemic embolism or stroke along with dual antiplatelet therapy to prevent coronary arterial thrombosis (CAT), is used. However, TAT has been associated with a significantly increased risk of bleeding. With the emergence of non-vitamin K antagonist oral anticoagulants (NOACs), randomized controlled trials have demonstrated a better risk-to-benefit ratio of dual antithrombotic therapy (DAT) in combination of a NOAC and with a P2Y12 inhibitor than vitamin K antagonist-based TAT. The results of these studies have impacted the recommendations of current international guidelines, which favor a DAT with a NOAC and P2Y12 inhibitor (especially clopidogrel) in this clinical setting. Additionally, aspirin can be administered during the periprocedural period, while the treatment duration of TAT should be as short as possible. In this article, we summarize the up-to-date evidence regarding antithrombotic regimens for AF patients with PCI or ACS, with a specific focus on the optimal approach and critical discussions of key scientific data and future developments for antithrombotic management in these patients.

scholarly journals Rivaroxaban in patients with atrial fibrillation: from research to real practice (based on REGistry of Long-term AnTithrombotic TherApy-2 (REGATA))

2021 ◽  
pp. 68-88
Author(s):  
E. S. Kropacheva ◽  
E. N. Krivosheeva ◽  
E. P. Panchenko
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Ischemic Stroke ◽  
Antithrombotic Therapy ◽  
Bleeding Risk ◽  
Cardiovascular Death ◽  
Cardiovascular Complications ◽  
Coronary Syndrome

Introduction. Despite the large evidence base for the use of rivaroxaban, cohort studies are interesting because shows the possibility of anticoagulant therapy in patients with high thromboembolic and bleeding risk and a burden of comorbidity in practice.Aim: to evaluate the efficacy and safety of rivaroxaban therapy in patients with atrial fibrillation in prospective REGATTA registry.Materials and methods. This study is a fragment of a single-center prospective REGATA registry (Registry of Long-term Antithrombotic Therapy (NCT043447187), conducted on the basis of the National Research Center of Cardiology of the Ministry of Health of the Russian Federation. 152 patients with high thromboembolic risk (median CHA2DS2-VASc = 4) received rivaroxaban therapy (median follow-up 1.5 years). The efficacy endpoint was the sum of cardiovascular complications (including cardiovascular death, ischemic stroke, and acute coronary syndrome). The safety endpoint bleedinds BARC types 2-5.Results. The frequency of cardiovascular events (combining cardiovascular death, ischemic stroke and acute coronary syndrome) was 5.8/100 patient-years. The use of a “reduced” dose of rivaroxaban was an independent predictor of the development of fatal cardiovascular complications. The rate of major bleeding was 3.7/100 patient-years, and the rate of clinical relevant bleedings was 19.4 /100 patientyears. The predictors of major/ clinical relevant bleedings were chronic kidney disease with a decrease in creatinine clearance of less than 50 ml/min and the anamneses of major/ clinical relevant bleedings.Conclusion. The main requirement for improving the safety of anticoagulants is follow up, focused in all changes in the cardiovascular and somatic status of the patient during treatment.

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