Elsevier

American Heart Journal

Volume 242, December 2021, Pages 71-81
American Heart Journal

Clinical Investigations
Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis

https://doi.org/10.1016/j.ahj.2021.08.014Get rights and content

Background

Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF).

Objective

To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF.

Design

Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019.

Participants

New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis.

Measurements

Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time.

Results

After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72).

Limitations

Residual confounding.

Conclusions

In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.

Section snippets

Background

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia1 affecting approximately 34 million individuals worldwide.2 AF increases the risk of ischemic stroke by 5 fold compared to the general population.3 Oral anticoagulants are the cornerstone of therapy in AF patients for the prevention of stroke and thromboembolism.4 In the presence of acute coronary syndrome (ACS), a comorbid condition in 21% to 34% of AF patients, concomitant treatment with anticoagulant, and antiplatelet

Data source

We used commercial data from Optum's de-identified Clinformatics Data Mart Database from January 2016 to June 2019. Information from 2015 was used for the ascertainment of baseline information only. The data capture the healthcare experience of a privately insured population in the United States. The administrative database includes de-identified individual-level data on enrollment, patient demographics, outpatient claims, inpatient claims, and prescription drug claims. Laboratory data were

Funding

No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.

Results

We identified a total of 2,906 and 1,253 new users of antiplatelet-DOAC and antiplatelet-warfarin, respectively. The relative use of warfarin versus DOACs demonstrated a gradual shift in prescribing from warfarin to DOACs over the course of the study period (Supplemental Figure S2). Among antiplatelet-DOAC users, 1,980 initiated antiplatelet-apixaban, 793 initiated antiplatelet-rivaroxaban, and 132 initiated antiplatelet-dabigatran. Table I summarizes baseline characteristics prior to PSM.

Discussion

This comparative effectiveness and safety study using real-world data suggests that the concomitant use of antiplatelet-DOAC may be a more favorable treatment choice than antiplatelet-warfarin in patients with concurrent ACS and AF. The potential benefits of antiplatelet-DOAC observed in the current analysis extended to the individual DOACs including antiplatelet-apixaban, antiplatelet-rivaroxaban, and antiplatelet-dabigatran.

In patients with AF, warfarin has been the drug of choice for

Conclusion

In real-world data of patients with concurrent AF and ACS, the use of antiplatelet-DOACs following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in ACS patients with AF requiring combined antiplatelet therapy.

Disclosures and confluce of interest

GKD received funding from the American Society of Hematology and National Institute of Health. GDB has serves as a consultant for Pfizer/Bristol-Myers Squibb, Janssen, Portola, and Acelis Connected Health. ED has received educational honorarium from Pfizer and has been awarded grant funding from Bristol-Myers-Squibb / Pfizer for an investigator initiated claims-based study. AC has served as a consultant for Synergy and his institution has received research support on his behalf from Alexion,

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit-sector.

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