Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; New York University School of Medicine, New York, New York.
Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Hellerup, Denmark; Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
J Am Coll Cardiol. 2018 Oct 9;72(15):1790-1800. doi: 10.1016/j.jacc.2018.07.054.
The optimal treatment strategy when combining antiplatelets with oral anticoagulants in patients with atrial fibrillation (AF) and myocardial infarction (MI) or undergoing percutaneous coronary intervention (PCI) is unknown.
The authors investigated the risk of bleeding, ischemic stroke, MI, and all-cause mortality associated with direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in combination with aspirin, clopidogrel, or both in patients with AF following MI and/or PCI.
Danish nationwide registries were used to identify patients with AF who were admitted with a MI and/or underwent PCI, between August 2011 and June 2017, treated with OAC in combination with antiplatelet(s). Patients were followed for 12 months or until an outcome, study end, or death. Standardized absolute risks were estimated on the basis of outcome-specific Cox regression models adjusted for potential confounders. Average treatment effects were obtained as standardized absolute risk differences (ARD) in risks at 3 and 12 months using the g-formula.
Overall, 3,222 patients were included in the study population, of which 875 (27%) were treated with VKA+single antiplatelet therapy (SAPT), 595 (18%) were treated with DOAC+SAPT, 1,074 (33%) were treated with VKA+dual antiplatelet therapy (DAPT), and 678 (22%) were treated with DOAC+DAPT. At 3 months, there was a significant difference in the absolute risk of MI associated with DOAC+SAPT compared with VKA+SAPT (3-month ARD -1.53% (95% confidence interval: -3.08% to -0.11%), with no significant differences found regarding bleeding, ischemic stroke, and all-cause mortality. Compared with VKA+DAPT, DOAC+DAPT was associated with a significantly reduced risk of bleeding (3-month ARD -1.96%, 95% confidence interval: -3.46% to -0.88%), with no significant difference in the absolute risk of all-cause mortality, stroke, or MI.
In a real-world population of AF patients with MI and/or after PCI, the authors found that DOAC in combination with DAPT was associated with a significantly decreased risk of bleeding and similar thromboembolic protection compared with VKA in combination with DAPT.
在合并使用抗血小板药物与口服抗凝药物的房颤（AF）合并心肌梗死（MI）或行经皮冠状动脉介入治疗（PCI）的患者中，最佳治疗策略尚不清楚。
本研究旨在探讨与维生素 K 拮抗剂（VKA）相比，直接口服抗凝剂（DOAC）与阿司匹林、氯吡格雷或两者联合应用于 AF 合并 MI 和/或 PCI 患者中的出血、缺血性卒中和 MI 以及全因死亡率风险。
利用丹麦全国性登记处，本研究纳入了 2011 年 8 月至 2017 年 6 月间因 MI 住院和/或接受 PCI 的 AF 患者，这些患者在接受 OAC 治疗的同时还接受了抗血小板药物（APC）治疗。对患者进行 12 个月的随访，直至发生终点事件、研究结束或死亡。采用基于特定结局的 Cox 回归模型调整潜在混杂因素后，估计标准化绝对风险。使用 g 公式获得 3 个月和 12 个月时风险的标准化绝对风险差异（ARD），以获得平均治疗效果。
本研究共纳入 3222 例患者，其中 875 例（27%）接受了 VKA+单药抗血小板治疗（SAPT），595 例（18%）接受了 DOAC+SAPT，1074 例（33%）接受了 VKA+双药抗血小板治疗（DAPT），678 例（22%）接受了 DOAC+DAPT。在 3 个月时，与 VKA+SAPT 相比，DOAC+SAPT 治疗与 MI 绝对风险降低相关（3 个月 ARD-1.53%，95%置信区间：-3.08%至-0.11%），但在出血、缺血性卒中和全因死亡率方面无显著差异。与 VKA+DAPT 相比，DOAC+DAPT 治疗的出血风险显著降低（3 个月 ARD-1.96%，95%置信区间：-3.46%至-0.88%），但全因死亡率、卒中和 MI 的绝对风险无显著差异。
在 AF 合并 MI 和/或 PCI 的真实世界人群中，与 VKA+DAPT 相比，DOAC+DAPT 治疗与显著降低出血风险相关，且血栓栓塞保护作用与 VKA+DAPT 相当。
