Chilbert Maya R, Reidy Sarah E, Clark Collin M, Guszkowski Marissa, Gargala Emma, Woodruff Ashley E
Buffalo General Medical Center, Buffalo, NY, USA.
University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA.
Hosp Pharm. 2022 Apr;57(2):253-259. doi: 10.1177/00185787211024602. Epub 2021 Jun 10.
Triple antithrombotic therapy including an anticoagulant, P2Y12 inhibitor, and aspirin increases bleed risk up to 27%. The components of this regimen can vary, which may impact bleed risk. To compare the safety of various triple antithrombotic regimens. An Institutional Review Board approved retrospective cohort study was conducted from 2014 to 2017. Patients admitted to a large urban health system on triple therapy were evaluated for inclusion. The primary outcome compared rates of International Society of Thrombosis and Hemostasis major and clinically relevant nonmajor bleeding during index admission or within 90 days in patients receiving warfarin, rivaroxaban, or apixaban; aspirin; and a P2Y12 inhibitor. A multivariable logistic regression assessed the association between bleeding, antithrombotic use, and relevant confounding variables. Three hundred and seventy-two patients were included: 238 patients received warfarin, 63 received rivaroxaban, and 71 received apixaban. Forty-five patients (12.1%) experienced a bleed, 25 of which (55.6%) were major. The rate of bleeding was 12.2% (n = 29) with warfarin, 14.3% (n = 9) with rivaroxaban, and 9.9% (n = 7) with apixaban ( = .7335). The use of prasugrel versus clopidogrel (OR 4.35, 95% CI 1.20-15.72; = .025) and admission hemoglobin less than 12 mg/dL (OR 2.54, 95% CI 1.28-5.04; = .008) were identified as risk factors associated with bleeding in the model. In patients on triple antithrombotic therapy, choice of oral anticoagulant did not impact bleeding rates, but use of prasugrel and a low baseline hemoglobin were associated with increased bleed rates which warrants further investigation.
包括一种抗凝剂、P2Y12抑制剂和阿司匹林的三联抗栓治疗会使出血风险增加至27%。该治疗方案的组成成分可能有所不同，这可能会影响出血风险。为比较各种三联抗栓方案的安全性，我们在2014年至2017年进行了一项经机构审查委员会批准的回顾性队列研究。对入住大型城市医疗系统且接受三联治疗的患者进行纳入评估。主要结局比较了接受华法林、利伐沙班或阿哌沙班、阿司匹林以及P2Y12抑制剂的患者在索引住院期间或90天内国际血栓与止血学会严重及临床相关非严重出血的发生率。多变量逻辑回归分析评估了出血、抗栓药物使用及相关混杂变量之间的关联。共纳入372例患者：238例接受华法林治疗，63例接受利伐沙班治疗，71例接受阿哌沙班治疗。45例患者（12.1%）发生出血，其中25例（55.6%）为严重出血。华法林治疗组的出血发生率为12.2%（n = 29），利伐沙班治疗组为14.3%（n = 9），阿哌沙班治疗组为9.9%（n = 7）（P = 0.7335）。在模型中，使用普拉格雷而非氯吡格雷（比值比4.35，95%置信区间1.20 - 15.72；P = 0.025）以及入院时血红蛋白低于12mg/dL（比值比2.54，95%置信区间1.28 - 5.04；P = 0.008）被确定为与出血相关的危险因素。在接受三联抗栓治疗的患者中，口服抗凝剂的选择不影响出血率，但使用普拉格雷和低基线血红蛋白与出血率增加相关，这值得进一步研究。
