Dual Antithrombotic Therapy Versus Anticoagulant Monotherapy for Major Adverse Limb Events in Patients with Concomitant Lower Extremity Arterial Disease and Atrial Fibrillation: A Propensity Score Weighted Analysis

Donna Shu-Han Lin; Hsu-Ping Wu; Wen-Jung Chung; Shu-Kai Hsueh; Po-Chao Hsu; Jen-Kuang Lee; Chun-Chi Chen; Hsuan-Li Huang

doi:10.1016/j.ejvs.2024.05.015

Dual Antithrombotic Therapy Versus Anticoagulant Monotherapy for Major Adverse Limb Events in Patients with Concomitant Lower Extremity Arterial Disease and Atrial Fibrillation: A Propensity Score Weighted Analysis

Eur J Vasc Endovasc Surg. 2024 May 14:S1078-5884(24)00393-9. doi: 10.1016/j.ejvs.2024.05.015. Online ahead of print.

Authors

Donna Shu-Han Lin¹, Hsu-Ping Wu², Wen-Jung Chung³, Shu-Kai Hsueh³, Po-Chao Hsu⁴, Jen-Kuang Lee⁵, Chun-Chi Chen⁶, Hsuan-Li Huang⁷

Affiliations

¹ Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
² Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital Hsinchu Branch, Hsinchu, Taiwan.
³ Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
⁴ Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
⁵ Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan; Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan. Electronic address: b85401104@gmail.com.
⁶ College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
⁷ Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan; School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan.

PMID: 38754724
DOI: 10.1016/j.ejvs.2024.05.015

Abstract

Objective: Patients with symptomatic lower extremity arterial disease (LEAD) are recommended to receive antiplatelet therapy, while direct oral anticoagulants (DOAC) are standard for stroke prevention in atrial fibrillation (AF). For patients with concomitant LEAD and AF, data comparing dual antithrombotic therapy - an antiplatelet agent used in conjunction with a DOAC - versus DOAC alone (DOAC monotherapy) are scarce. This retrospective cohort study, based on data from the Taiwan National Health Insurance Research Database, aimed to compare the efficacy and safety of these antithrombotic strategies.

Methods: Patients with AF who underwent revascularisation for LEAD between 2012 - 2020 and received any DOAC within 30 days of discharge were included. Patients were grouped by antiplatelet agent exposure into the dual antithrombotic therapy and DOAC monotherapy groups. Inverse probability of treatment weighting was used to mitigate selection bias. Major adverse limb events (MALE), ischaemic stroke/systemic embolism, and bleeding outcomes were compared. Patients were followed until the occurrence of any study outcome, death, or up to two years.

Results: A total of 1470 patients were identified, with 736 in the dual antithrombotic therapy group and 734 in the DOAC monotherapy group. Among them, 1 346 patients received endovascular therapy as the index revascularisation procedure and 124 underwent bypass surgery. At two years, dual antithrombotic therapy was associated with higher risks of MALE than DOAC monotherapy (subdistribution hazard ratio [SHR] 1.34, 95% CI 1.15 - 1.56), primarily driven by increased repeat revascularisation. Dual antithrombotic therapy was also associated with higher risks of major bleeding (SHR 1.43, 95% CI 1.05 - 1.94) and gastrointestinal bleeding (SHR 2.17, 95% CI 1.42 - 3.33) than DOAC monotherapy.

Conclusion: In patients with concomitant LEAD and AF who underwent peripheral revascularisation, DOAC monotherapy was associated with lower risks of MALE and bleeding events than dual antithrombotic therapy.

Keywords: Adverse limb events; Atrial fibrillation; Bleeding; Dual antithrombotic therapy; Peripheral artery occlusive disease; Systemic embolism.