Otsuki Hisao, Yamaguchi Junichi, Kamishima Kazuho, Arashi Hiroyuki, Hagiwara Nobuhisa
Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo, 162-8666, Japan.
Heart Vessels. 2018 Sep;33(9):986-996. doi: 10.1007/s00380-018-1148-y. Epub 2018 Mar 16.
Previous reports have focused on cardiovascular and bleeding events in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). However, antithrombotic treatment strategies and clinical outcomes after second-generation drug-eluting stents (DES) implantation in AF patients remain to be determined. We enrolled 244 consecutive AF patients treated with second-generation DES. The study population was derived from multi-center AF registry (including 8 centers in Japan) from 2010 to 2012. Prescription of antithrombotic agents and clinical outcomes were retrospectively examined. Ninety-two patients (37.7%) were prescribed dual antiplatelet therapy (DAPT) at discharge and 152 patients (62.3%) were given DAPT plus oral anticoagulation (OAC) with warfarin. The median follow-up period was 730 days. Kaplan-Meier analysis showed that major adverse cardiac and cerebrovascular events (MACCE) were not significantly different (2-year event rate, 17.6 vs. 13.5%, p = 0.37), but bleeding events were significantly higher in the DAPT plus OAC group than in the DAPT group (2-year event rate, 6.1 vs. 17.9%, p = 0.033). In a sub-analysis of DAPT plus OAC patients, adequate time in the therapeutic range (TTR) group (TTR ≥ 65%) was not significantly different from the suboptimal OAC group (TTR < 65%) for bleeding events, but it had a lower incidence of MACCE, resulting in better net clinical outcomes (composite of MACCE and major bleeding, 2-year event rate, 9.2 vs. 27.8%, p = 0.008). DAPT plus OAC remains more common in AF patients undergoing PCI with second-generation DES. Under adequate TTR, DAPT plus OAC showed better net clinical outcomes by reducing MACCE without increasing bleeding.
既往报告主要关注接受经皮冠状动脉介入治疗（PCI）的心房颤动（AF）患者的心血管和出血事件。然而，第二代药物洗脱支架（DES）植入AF患者后的抗栓治疗策略及临床结局仍有待确定。我们纳入了244例连续接受第二代DES治疗的AF患者。研究人群来自2010年至2012年的多中心AF注册研究（包括日本的8个中心）。对患者出院时抗栓药物的处方及临床结局进行回顾性分析。92例患者（37.7%）出院时接受双联抗血小板治疗（DAPT），152例患者（62.3%）接受DAPT加华法林口服抗凝（OAC）治疗。中位随访期为730天。Kaplan-Meier分析显示，主要不良心脑血管事件（MACCE）无显著差异（2年事件发生率分别为17.6%和13.5%，p = 0.37），但DAPT加OAC组的出血事件显著高于DAPT组（2年事件发生率分别为6.1%和17.9%，p = 0.033）。在DAPT加OAC患者的亚组分析中，治疗范围内的适当时间（TTR）组（TTR≥65%）与非最佳OAC组（TTR<65%）的出血事件无显著差异，但MACCE发生率较低，从而获得更好的净临床结局（MACCE和大出血的复合事件，2年事件发生率分别为9.2%和27.8%，p = 0.008）。DAPT加OAC在接受第二代DES PCI的AF患者中仍然更为常见。在适当的TTR水平下，DAPT加OAC通过减少MACCE且不增加出血，显示出更好的净临床结局。
