An analysis of antithrombotic therapy in elderly patients with atrial fibrillation undergoing percutaneous coronary interventions

Abstract

As a result of large, randomized trials and updates to clinical guidelines, antithrombotic therapy following percutaneous coronary intervention (PCI) has changed in recent years for patients with nonvalvular atrial fibrillation (NVAF). The purpose of this study was to investigate the real-world data of antithrombotic regimens at discharge and their evolving trends, as well as compare the effect of different therapies on the incidence of major cardiovascular and cerebrovascular ischemic events (MACCEs) and bleeding events in elderly patients. An analysis of 6298 stent implantation patients from 2016 to 2018 was carried out retrospectively. Atrial fibrillation (AF) patients ages 65 and older were divided into two groups according to the antithrombotic regimens prescribed at hospital discharge: dual antiplatelet aggregation treatment group (DAPT) and anticoagulant treatment and antiplatelet aggregation treatment group (ATT). Baseline characteristics, efficacy endpoints (MACCEs/cerebrovascular ischemic events) and safety endpoints (bleeding events) were analysed and compared between the different antithrombotic regiments. During 2016 to 2018, the use of oral anticoagulants (OAC) increased from 16.3% to 54.1% (p trend <0.01). Since the introduction of non-vitamin K antagonist oral anticoagulants (NOACs), warfarin usage has decreased from 100% to 41.7%, and NOACs have rapidly replaced warfarin. The rate of persistent AF in the ATT group was significantly higher than the rate in the DAPT group (79.6% vs 59.7%, p = 0.01), and the ATT group used more proton pump inhibitors (PPI) than the DAPT group (23.3% vs 11.8%, p = 0.01). A significant decrease was observed in MACCEs (10.7% vs 26.0%, p < 0.01) and cerebrovascular ischemic events (2.9% vs 11.8%, p = 0.01) in the ATT group compared with the DAPT group. According to the ATT subgroup analysis, there was a significant difference in the incidence of overall bleeding between the triple anticoagulant therapy group and the dual anticoagulant therapy group (DT) (18.0% vs 2.4%, p = 0.02). MACCEs were predicted independently by ATT and CHA₂ DS₂ -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category) scores, whereas bleeding was predicted independently by PPI use and HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol) scores. As a result of NOAC introduction and use, the combination of antithrombotic regimens at discharge for elderly patients with AF after PCI has changed rapidly over the past few years toward a higher use of ATTs, whereas patients with AF undergoing PCI still rarely receive an appropriate antithrombotic regimen. It is essential to conduct ATT in elderly patients who are undergoing PCI, and further DT may be more appropriate.

Keywords: antiplatelet therapy; antithrombotic therapy; atrial fibrillation; elderly patients; percutaneous coronary intervention.