Clinical InvestigationsCardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis
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.
References (43)
- et al.
The global burden of atrial fibrillation and stroke: a systematic review of the epidemiology of atrial fibrillation in regions outside North America and Europe
Chest
(2012) - et al.
AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart rhythm society
J Am Coll Cardiol
(2019) - et al.
Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial
Lancet
(2013) - et al.
Combining oral anticoagulants with platelet inhibitors in patients with atrial fibrillation and coronary disease
J Am Coll Cardiol
(2018) - et al.
Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial
The Lancet (British edition)
(2019) - et al.
Hospitalization for hemorrhage among warfarin recipients prescribed amiodarone
Am J Cardiol
(2013) - et al.
2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American college of cardiology/American heart association task force on clinical practice guidelines
J Am Coll Cardiol
(2016) - et al.
Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial
Lancet
(2019) - et al.
Worldwide epidemiology of atrial fibrillation: a global burden of disease 2010 Study
Circulation
(2014) - et al.
Atrial fibrillation as an independent risk factor for stroke: the Framingham Study
Stroke
(1991)