Mennuni Marco G, Halperin Jonathan L, Bansilal Sameer, Schoos Mikkel M, Theodoropoulos Kleanthis N, Meelu Omar A, Sartori Samantha, Giacoppo Daniele, Bernelli Chiara, Moreno Pedro R, Krishnan Prakash, Baber Usman, Lucarelli Carla, Dangas George D, Sharma Samin K, Kini Annapoorna S, Tamburino Corrado, Chieffo Alaide, Colombo Antonio, Presbitero Patrizia, Mehran Roxana
The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Heart, Mount Sinai Medical Center, New York, New York; Cardiovascular Department, University of Milan, Humanitas Research Hospital, Rozzano, Milan, Italy.
The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Heart, Mount Sinai Medical Center, New York, New York.
Am J Cardiol. 2015 Jul 1;116(1):37-42. doi: 10.1016/j.amjcard.2015.03.033. Epub 2015 Apr 8.
Patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) are at elevated risk for bleeding and thromboembolic ischemic events. Currently, guidelines on antithrombotic treatment for these patients are based on weak consensus. We describe patterns and determinants of antithrombotic prescriptions in this population. The Antithrombotic Strategy Variability in Atrial Fibrillation and Obstructive Coronary Disease Revascularized with PCI Registry was an international observational study of 859 consecutive patients with AF who underwent PCI from 2009 to 2011. Patients were stratified by treatment at discharge with either dual antiplatelet therapy (DAPT; aspirin plus clopidogrel) or triple therapy (TT; warfarin plus DAPT). Bleeding and thromboembolism risks were assessed by the HAS-BLED and CHADS2 scores, respectively, and predictors of TT prescription at discharge were identified. Major adverse cardiovascular events and clinically relevant bleeding (Bleeding Academic Research Consortium score ≥2) at 1-year follow-up were compared across antithrombotic regimens. Compared with patients on DAPT (n = 488; 57%), those given TT (n = 371; 43%) were older, with higher CHADS2 scores, lower left ventricular ejection fraction, and more often had permanent AF, single-vessel coronary artery disease, and bare-metal stents. In multivariate analysis, increasing thromboembolic risk (CHADS2) was associated with a higher rate of TT prescription at discharge (intermediate vs low CHADS2: odds ratio 2.2, 95% confidence interval [CI] 2.0 to 3.3, p <0.01; high vs low CHADS2: odds ratio 1.6, 95% CI 2.6 to 4.3, p <0.01 for TT). However, there was no significant association between bleeding risk and TT prescription in the overall cohort or within each CHADS2 risk stratum. The rates of major adverse cardiovascular events were similar for patients discharged on TT or DAPT (20% vs 17%, adjusted hazard ratio 0.8, 95% CI 0.5 to 1.1, p = 0.19), whereas the rate of Bleeding Academic Research Consortium ≥2 bleeding was higher in patients discharged on TT (11.5% vs 6.4%, adjusted hazard ratio 1.8, 95% CI 1.1 to 2.9, p = 0.02). In conclusion, the choice of the intensity of antithrombotic therapy correlated more closely with the risk of ischemic rather than bleeding events in this cohort of patients with AF who underwent PCI.
接受经皮冠状动脉介入治疗（PCI）的心房颤动（AF）患者发生出血和血栓栓塞性缺血事件的风险升高。目前，针对这些患者的抗栓治疗指南基于微弱的共识。我们描述了该人群抗栓处方的模式和决定因素。“PCI治疗的房颤和阻塞性冠状动脉疾病抗栓策略变异性登记研究”是一项针对2009年至2011年连续859例接受PCI的AF患者的国际观察性研究。患者根据出院时接受双联抗血小板治疗（DAPT；阿司匹林加氯吡格雷）或三联治疗（TT；华法林加DAPT）进行分层。分别通过HAS - BLED和CHADS2评分评估出血和血栓栓塞风险，并确定出院时TT处方的预测因素。比较了不同抗栓方案在1年随访时的主要不良心血管事件和临床相关出血（出血学术研究联盟评分≥2）情况。与接受DAPT的患者（n = 488；57%）相比，接受TT的患者（n = 371；43%）年龄更大，CHADS2评分更高，左心室射血分数更低，且更常患有永久性房颤、单支冠状动脉疾病和裸金属支架。在多变量分析中，血栓栓塞风险增加（CHADS2）与出院时TT处方率较高相关（CHADS2中度与低度：比值比2.2，95%置信区间[CI] 2.0至3.3，p <0.01；CHADS2高度与低度：TT的比值比1.6，95% CI 2.6至4.3，p <0.01）。然而，在整个队列或每个CHADS2风险分层中，出血风险与TT处方之间无显著关联。接受TT或DAPT出院的患者主要不良心血管事件发生率相似（20%对17%，调整后风险比0.8，95% CI 0.5至1.1，p = 0.19），而接受TT出院的患者出血学术研究联盟≥2级出血发生率更高（11.5%对6.4%，调整后风险比1.8，95% CI 1.1至2.9，p = 0.02）。总之，在这群接受PCI的AF患者中，抗栓治疗强度的选择与缺血事件风险的相关性比与出血事件风险的相关性更密切。
