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No benefit for antiplatelets with VKA in AF

In atrial fibrillation (AF) patients with stable coronary artery disease, the addition of antiplatelet therapy to vitamin K antagonist (VKA) therapy is not associated with a reduction in risk of recurrent coronary events or thromboembolism, while risk of bleeding is increased significantly, according to a study published recently in Circulation.1 The common practice of adding antiplatelet therapy to oral VKA anticoagulation in patients with AF and stable coronary artery disease should be reassessed, say the authors.

AF patients with stable coronary artery disease (defined as 12 months from an acute coronary event) between 2002 and 2011 were identified. The subsequent risk of cardiovascular events and serious bleeding events (those that required hospitalisation) was examined with adjusted Cox regression models according to ongoing antithrombotic therapy. A total of 8,700 patients were included (mean age, 74.2 years; 38% women). During a mean follow-up of 3.3 years, crude incidence rates were 7.2, 3.8, and 4.0 events per 100 person-years for myocardial infarction/coronary death, thromboembolism, and serious bleeding, respectively.

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Dr Morten Lamberts (Copenhagen University Hospital Gentofte, Denmark)

Relative to VKA monotherapy, the risk of myocardial infarction/coronary death was similar for VKA plus aspirin and VKA plus clopidogrel. The risk of thromboembolism was comparable in all regimens that included VKA, whereas the risk of bleeding increased when aspirin (hazard ratio, 1.50 [95% confidence interval, 1.23–1.82]) or clopidogrel (hazard ratio, 1.84 [95% confidence interval, 1.11–3.06]) was added to VKA.

Speaking to BJC Arrhythmia Watch, co-author Dr Morten Lamberts (Copenhagen University Hospital Gentofte, Denmark) said: “This is the best possible evidence for now on no additional benefit of adding an antiplatelet agent on top on vitamin K antagonist in AF patients with stable ischaemic heart disease. Indeed, we found combination therapy was clearly and significantly associated with increased risk of serious bleeding and associated mortality.”

“A significant, unresolved question is how do deal with this information if patients are taking novel oral anticoagulants (NOACs). Immediately following a myocardial infarction we know from trials that with combination therapy of NOACs and antiplatelets, severe bleeding is increased but it is unknown whether this can be extrapolated to AF patients with stable ischaemic heart disease,” Dr Lamberts added. “Current European guidelines, and my personal opinion, suggest that patients with AF and prior myocardial infarction should only receive old or new oral anticoagulant as thromboprophylaxis, according to the CHA2DS2-VASc risk stratification tool,” he concluded.

References

1. Lamberts M, Gislason GH, Lip GYH, et al. Antiplatelet therapy for stable coronary artery disease in atrial fibrillation patients taking an oral anticoagulant: a nationwide cohort study. Circulation 2014;129:1577–85. http://dx.doi.org/10.1161/​CIRCULATIONAHA.113.004834

Published on: April 30, 2014

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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