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Frequent and possibly inappropriate use of combination therapy with an oral anticoagulant and antiplatelet agents in patients with atrial fibrillation in Europe
  1. Raffaele De Caterina1,2,
  2. Bettina Ammentorp3,
  3. Harald Darius4,
  4. Jean-Yves Le Heuzey5,
  5. Giulia Renda1,
  6. Richard John Schilling6,
  7. Tessa Schliephacke3,
  8. Paul-Egbert Reimitz3,
  9. Josef Schmitt3,
  10. Christine Schober3,
  11. José Luis Zamorano7,
  12. Paulus Kirchhof8,9
  13. for the PREFER in AF Registry Investigators
  1. 1Institute of Cardiology and Center of Excellence on Aging, G. d'Annunzio, University Chieti-Pescara, Pisa, Italy
  2. 2Fondazione G. Monasterio, Pisa, Italy
  3. 3Daiichi Sankyo Europe, Munich, Germany
  4. 4Vivantes Hospital Neukölln, Berlin, Germany
  5. 5Cardiology and Arrhythmology, Georges Pompidou Hospital, René Descartes University, Paris, France
  6. 6Barts and St Thomas Hospital, London, UK
  7. 7Department of Cardiology, University Hospital Ramón y Cajal, Madrid, Spain
  8. 8University of Birmingham Centre for Cardiovascular Sciences and SWBH NHS Trust, Birmingham, UK
  9. 9Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
  1. Correspondence to Professor Raffaele De Caterina, Institute of Cardiology, “G. d'Annunzio” University—Chieti, C/o Ospedale SS. Annunziata, Via dei Vestini, Chieti 66013, Italy; rdecater{at}


Purpose Combined oral anticoagulant (OAC) and antiplatelet (AP) therapy is generally discouraged in atrial fibrillation (AF) outside of acute coronary syndromes or stenting because of increased bleeding. We evaluated its frequency and possible reasons in a contemporary European AF population.

Methods The PREvention oF thromboembolic events–European Registry in Atrial Fibrillation (PREFER in AF) prospectively enrolled AF patients in France, Germany, Austria, Switzerland, Italy, Spain and the UK from January 2012 to January 2013. We evaluated patterns of combined VKA-AP therapy in this population.

Results Out of 7243 patients enrolled, 5170 (71.4%) were treated with OAC alone, 808 (11.2%) with AP alone and 791 (10.9%) with a combination of OAC and one (dual) or two AP (triple combination therapy). Compared with patients only prescribed OAC, patients on combination treatment had similar Body Mass Index, but more frequently diabetes (p<0.05), dyslipidaemia (p<0.01), coronary heart disease (54.2 vs 18.6%; p<0.01) or peripheral arterial disease (10.2 vs 3.7%; p<0.01). Accordingly, they had a higher mean CHA2DS2VASc (3.7 vs 3.4), and HAS-BLED (2.7 vs 1.9) scores (for both, p<0.01).

Of the 660 patients on dual AP+OAC combination therapy, 629 (95.3%) did not have an accepted indication. Out of the 105 patients receiving triple combination therapy, 67 (63.8%) did not have an accepted indication.

Conclusions The combined use of OAC and AP therapy is not uncommon in AF, largely inappropriate, explained by the coexistence of coronary or peripheral arterial disease, and not influenced by considerations on the risk of bleeding.

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