Optimal antithrombotic regimen for AF patients undergoing PCI should not include aspirin

By Will Boggs MD

NEW YORK (Reuters Health) - 9/3/2020

The optimal antithrombotic regimen for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) appears to be a non-vitamin K antagonist oral anticoagulant (NOAC) plus a P2Y12 inhibitor without long-term aspirin, according to an updated network meta-analysis.

A 2019 network meta-analysis (https://bit.ly/39oWMP4) found that a regimen of NOAC plus a P2Y12 inhibitor without aspirin was associated with lower bleeding rates, compared with a regimen of vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT).

Dr. Renato D. Lopes of Duke Clinical Research Institute, in Durham, North Carolina, and colleagues updated the earlier network meta-analysis by including data from ENTRUST-AF PCI, which compared the safety of edoxaban plus a P2Y12 inhibitor versus VKA plus DAPT in 1,506 patients with AF who underwent PCI.

Overall, their network meta-analysis included data from 11,542 patients who participated in one of four randomized controlled trials, they note in JAMA Cardiology.

As in the earlier analysis, the odds of all safety outcomes, including intracranial hemorrhage, were significantly lower for NOAC plus P2Y12 inhibitor than for VKA plus DAPT.

Discontinuing the aspirin regimen (either with NOAC or VKA) was consistently associated with a lower risk of trial-defined bleeding compared with regimens including aspirin.

The four treatment regimens examined (VKA plus DAPT or P2Y12 inhibitor and NOAC plus DAPT or P2Y12 inhibitor) did not differ significantly in terms of the composite of major adverse cardiovascular events (MACE) or its individual components (death, myocardial infarction, stroke, or stent thrombosis).

"We believe that the findings of this study support the use of regimens in which aspirin therapy is discontinued a few days after PCI," the authors conclude. "A regimen that includes a NOAC plus a P2Y12 inhibitor seems to be the most favorable treatment option and may be the preferred antithrombotic regimen for most of these patients."

Dr. Dominick Angiolillo, who directs the cardiovascular research program at the University of Florida College of Medicine-Jacksonville, told Reuters Health by email, "In general, there is agreement that patients should minimize as much as possible their duration of dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor). In particular, while all patients should receive aspirin during the peri-PCI period, this should be discontinued as soon as possible, including by time of hospital discharge. Only in patients considered to be at high thrombotic risk and low bleeding risk should aspirin be continued, but not for more than one month."

"Ultimately, a NOAC at a stroke-prevention-dosing regimen should be preferred over a VKA," said Dr. Angiolillo, who was not involved in the study. "In brief, a P2Y12 antagonist plus a NOAC is the treatment regimen of choice for most patients, as also supported by this updated meta-analysis. Similar recommendations are provided by North American expert consensus for the antithrombotic management of AF patients undergoing PCI."

Dr. Uwe Zeymer of Klinikum der Stadt Ludwigshafen Am Rhein, in Ludwigshafen Am Rhein, Germany, who has reviewed the therapeutic options for these patients, told Reuters Health by email, "Long-term triple therapy with VKA is not recommended any more. NOACs should be preferred as dual antithrombotic therapy in combination with clopidogrel."

"It seems difficult to compare the four trials, so a specific recommendation for one of the four NOACs seems not justified," added Drl Zeymer, who also was not involved in the new analysis.

The study did not have commercial funding, but many of the authors report ties to one or more manufacturers of antithrombotic agents. Dr. Lopes did not respond to a request for comments.

SOURCE: https://bit.ly/39zeFuR

JAMA Cardiology, online February 26, 2020.

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