PCI in patients with atrial fibrillation - triple therapy with aspirin, clopidogrel and VKA, a single center experience

Abstract

Background: Patients with atrial fibrillation (AF) are of increased risk for stroke and systemic embolism and often have concomitant coronary artery disease (CAD). Current clinical practice in patients with AF and CAD undergoing percutaneous coronary interventions (PCI) with stent implantation involves dual an-tiplatelet therapy and the continuation of oral anticoagulation. Although generally perceived as a high bleeding risk population, there is uncertainty about the bleeding rates in these patients. We analyzed subsequent patients admitted to a university hospital medical center (2000 until 2011) treated with PCI, stent and triple therapy. Methods: The fulltext inpatient and cathlab database including discharge summaries were screened for the key words PCI, Stent, Aspirin, Clopidogrel, and Phenprocouomon. We identified 88 patients with triple therapy for at least 4 weeks following stent implantation and for whom follow up within the inpatient database was available. CHA2DS2VASc and HASBLED scores were calculated on the basis of the current patient diagnosis at the time of the index PCI. Major bleeding events were defined as gastrointestinal, pulmonary, retroperitoneal, intracerebral, intraocular or intraarticular bleeding. Results: Out of the 88 patients, 72% received triple therapy because of AF and 28% for other reasons (including markedly reduced ejection fraction, left ventricular thrombus and pulmonary embolism). 55% of all patients had persistent, 17% had intermittent AF at the time of the index PCI. The mean CHA2DS2VASc and HASBLED scores were 3.3 and 2.7 respectively. 44% of the patients had a GFR <60ml/min. The mean duration of triple therapy was 17.3 weeks. During this period there was no stent thrombosis or target vessel revascularization in the observed population. Major bleeding occurred in 9.1% of all patients, while gastrointestinal bleedings were the most frequent bleeding events (5.7%) followed by pulmonary bleedings (3.4%). No intracerebral bleedings were observed. Conclusion: Triple therapy consisting of dual antiplatelet therapy with aspirin and clopidogrel and oral anticoagulation with phenprocoumon is associated with an elevated risk for major bleeding events. In a real-world retrospective analysis of patients treated with PCI and stent followed by triple therapy for at least 4 weeks, we observed major bleeding events with a frequency of 9.1%. The majority of bleedings were gastrointestinal (GI). Our data are in line with reports of other groups and generate the hypothesis that GI-bleedings are the major obstacle associated with triple therapy.