Chest
Volume 134, Issue 3, September 2008, Pages 559-567
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Original Research
Thrombosis
Increased Major Bleeding Complications Related to Triple Antithrombotic Therapy Usage in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Artery Stenting

https://doi.org/10.1378/chest.08-0350Get rights and content

Background

The optimal antithrombotic therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of antithrombotic therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S.

Methods

We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple antithrombotic therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [≤ 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded.

Results

We studied 104 patients (mean age ± SD, 72 ± 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p = 0.006) but not of EMB (5.8% vs non-TT, 11.3%; p = 0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p = 0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p = 0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p = 0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p = 0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p = 0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p = 0.53).

Conclusion

A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.

Section snippets

Materials and Methods

A retrospective analysis of our computerized database including all patients who were discharged from our hospital after PCI-S between January 2002 and December 2006 was performed. All AF patients with indication for OAC16 who had undergone PCI-S and belonged to our local patient catchment area (a population of 226,000) were included in the analysis.

We recorded clinical and demographic characteristics of the patients, stroke risk factors, and antithrombotic therapy use before percutaneous

Results

We identified 104 patients with AF who had undergone PCI-S over the study period (Table 1). Of the 104 study patients, only 7 patients had been included in our earlier report8 on mortality and outcomes in AF patients undergoing PCI. Median follow-up was 12 months (IQR, 10 to 12 months). All patients were followed up for at least 6 months, although 1-year follow-up was completed in 68% of the study population. The study population was elderly, with a high prevalence of comorbidities. The

Discussion

The present study has the following major findings in regard to bleeding in our AF patients undergoing PCI-S: (1) a high incidence of short-term and long-term major bleeding complications; (2) the identification of different predictors of major bleeding according to the time from the PCI-S: GP IIb/IIIa inhibitor use and the presence of multivessel/left main artery disease were independent predictors of EMB, while TT regimen and EMB were independent predictors of LMB; and (3) a high complexity

Conclusion

This study shows that AF patients with indication for OAC who undergo PCI-S represent a complex population with multiple comorbidities and a high rate of short-term and long-term major bleeding complications. Moreover, different predictors of major bleeding according to the time from the PCI-S were identified, being GP IIb/IIIa inhibitors and TT use being the main factors implicated in EMB and LMB, respectively. Although TT may theoretically represent the best antithrombotic therapy option for

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    The authors have no conflicts of interest to disclose.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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