88One-year outcomes of triple therapy and adherence with ESC guidelines in patients with AF undergoing PCI in a teaching hospital

Abstract

Background/Introduction: Oral anticoagulation is the corner-stone for stroke prevention in Atrial Fibrillation (AF). Following Percutaneous Coronary Intervention (PCI) the risk of bleeding increase due to concomitant prescription of antiplatelet agents. The 2016 European Society of Cardiology( ESC) guidelines for non valvular AF provide clear recommendations for triple therapy , Combination of two anti-platelet and oral anticoagulant in patients with underlying AF undergoing PCI, either electively or for acute coronary syndrome (ACS). The risk of such therapy is based on treatment duration and patient characteristics. Purposes/Aims: To ascertain the adherence to triple therapy guidelines and advers outcomes in patients on triple therapy. Methodology: We reviewed all AF patients undergoing PCI in Birmingham City Hospital from September 2015 to September 2016 with Warfarin or Non-vitamin K Oral AntiCoagulant (NOAC). Data was obtained from British Cardiovascular Intervention Society (BCIS) database, electronic patient record, catheter laboratory operation reports and blood bank. The primary ouctomes at minimum 12 month follow up were: major bleeding (>2g/L drop in Hb ) requiring blood transfusion or intra-cranial haemorrhage and all cause mortality. Result(s): The mean age in our cohart was 73.2 years and 66.7% were male . Hypertension (83%), previous Myocardial infarction (73%) and Left ventricle dysfunction (46%) were the most common comorbidities. 74(67.6%) of patients had a CHA2DS2VASc score of 4 or more suggesting a high risk for thromboembolic complications. 57(51.3%) patients presented with ACS while 54 (48.6%) were elective . Rivaroxaban 15mg was the most commonly prescribed NOAC at 54 (48.6%) patients on this agent followed by Warfarin 34 (30.6%), Apixaban 17 (15.3%), Dabigatran 5 (4.5%) and Edoxaban 1 (0.9%). The most commonly prescribed combination of antiplatelet was Aspirin/Clopidogrel 102 ( 91.8%) followed by Aspirin /Ticagrelor (2.2%) and Clopidogrel monotherapy (3.3%). After a least 12 months follow up 6 (6.6%) patients had a major bleed requiring blood transfusion ,3 (3.3%) had non-fatal intracranial haemorrhage . All-cause mortality was 9 (9.9%). 2 of these deaths were due to major bleeding.4 deaths occured within the first month triple therapy, further 4 patients died between 1-3 months. 88.8% of all deaths occured within 3 months on triple therapy. Conclusion(s): Risk of major bleeding was lower than similar trials like PIONEER -AF. The observed risk of mortality was higher, this could be due to measuring all-cause mortality rather than cardiovascular mortality. Large registry is needed to enable physicians to make better informed decision for such high risk patients.