Warfarin in Older Atrial Fibrillation Patients With NSTEMI
Background We sought to determine the risk of readmission for bleeding and major cardiac events in stented non–ST-segment elevation myocardial infarction (NSTEMI) atrial fibrillation (AF) patients.
Methods For this patient population, selection of an antithrombotic strategy poses a unique challenge in clinical practice, and comparative outcome data are sparse. We linked NSTEMI patients aged ≥65 years in the CRUSADE Registry (2003–2006) to Medicare claims data. We examined patients with AF who received coronary stenting and either dual antiplatelet therapy (DAPT, aspirin + clopidogrel) or triple therapy (DAPT + warfarin) upon discharge. Multivariable Cox analysis was used to compare the 1-year risks of major cardiac events and readmission for bleeding.
Results We identified 1,648 stented NSTEMI AF patients. Of these, 1,200 (73%) received DAPT, and 448 (27%) received triple therapy at hospital discharge. Predicted thromboembolic and bleeding risks did not appear to influence the decision to receive DAPT or triple therapy. At 1 year, 20.4% had a major cardiac event, and 13.5% were admitted for bleeding. Use of triple therapy relative to DAPT at discharge was associated with a similar adjusted risk of major cardiac events (adjusted hazard ratio 0.94, CI 0.73–1.21) but a trend toward increased risk of readmission for bleeding (hazard ratio 1.29, CI 0.96–1.74, P = .09).
Conclusions In routine practice and in contrast with practice recommendations, most elderly NSTEMI patients with AF who undergo percutaneous coronary intervention with stent placement receive DAPT rather than triple therapy at discharge. Those receiving triple therapy versus DAPT had a similar risk of an ischemic event but a trend toward increased bleeding.
Coronary stenting in patients with myocardial infarction (MI) and concomitant atrial fibrillation (AF) poses a common treatment dilemma concerning the selection of a safe and effective antithrombotic strategy, and few observational or clinical trial data exist for this high-risk group. Nevertheless, recent expert consensus reports and guidelines recommend "triple therapy" (aspirin + warfarin + clopidogrel) for the prevention of recurrent thromboembolic events in high-risk patients with AF and acute coronary artery disease. Selecting a regimen is particularly challenging in older adults because elderly patients are at significantly higher risk for thromboembolic events than their younger counterparts, yet they are also at higher risk for bleeding with more aggressive antithrombotic therapy. Consequently, assessing thromboembolic risk on an individual level is crucial for optimizing patient outcomes.
We sought to compare the impact of dual antiplatelet therapy (DAPT) versus DAPT + warfarin on subsequent rates of major ischemic events and bleeding in older AF patients treated in routine practice with percutaneous coronary intervention (PCI) and stenting for non–ST-segment elevation MI (NSTEMI). We studied patients aged ≥65 years who were enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Registry.
Abstract and Introduction
Abstract
Background We sought to determine the risk of readmission for bleeding and major cardiac events in stented non–ST-segment elevation myocardial infarction (NSTEMI) atrial fibrillation (AF) patients.
Methods For this patient population, selection of an antithrombotic strategy poses a unique challenge in clinical practice, and comparative outcome data are sparse. We linked NSTEMI patients aged ≥65 years in the CRUSADE Registry (2003–2006) to Medicare claims data. We examined patients with AF who received coronary stenting and either dual antiplatelet therapy (DAPT, aspirin + clopidogrel) or triple therapy (DAPT + warfarin) upon discharge. Multivariable Cox analysis was used to compare the 1-year risks of major cardiac events and readmission for bleeding.
Results We identified 1,648 stented NSTEMI AF patients. Of these, 1,200 (73%) received DAPT, and 448 (27%) received triple therapy at hospital discharge. Predicted thromboembolic and bleeding risks did not appear to influence the decision to receive DAPT or triple therapy. At 1 year, 20.4% had a major cardiac event, and 13.5% were admitted for bleeding. Use of triple therapy relative to DAPT at discharge was associated with a similar adjusted risk of major cardiac events (adjusted hazard ratio 0.94, CI 0.73–1.21) but a trend toward increased risk of readmission for bleeding (hazard ratio 1.29, CI 0.96–1.74, P = .09).
Conclusions In routine practice and in contrast with practice recommendations, most elderly NSTEMI patients with AF who undergo percutaneous coronary intervention with stent placement receive DAPT rather than triple therapy at discharge. Those receiving triple therapy versus DAPT had a similar risk of an ischemic event but a trend toward increased bleeding.
Introduction
Coronary stenting in patients with myocardial infarction (MI) and concomitant atrial fibrillation (AF) poses a common treatment dilemma concerning the selection of a safe and effective antithrombotic strategy, and few observational or clinical trial data exist for this high-risk group. Nevertheless, recent expert consensus reports and guidelines recommend "triple therapy" (aspirin + warfarin + clopidogrel) for the prevention of recurrent thromboembolic events in high-risk patients with AF and acute coronary artery disease. Selecting a regimen is particularly challenging in older adults because elderly patients are at significantly higher risk for thromboembolic events than their younger counterparts, yet they are also at higher risk for bleeding with more aggressive antithrombotic therapy. Consequently, assessing thromboembolic risk on an individual level is crucial for optimizing patient outcomes.
We sought to compare the impact of dual antiplatelet therapy (DAPT) versus DAPT + warfarin on subsequent rates of major ischemic events and bleeding in older AF patients treated in routine practice with percutaneous coronary intervention (PCI) and stenting for non–ST-segment elevation MI (NSTEMI). We studied patients aged ≥65 years who were enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) Registry.
SHARE
