What does this research mean for the field?

In elderly patients with acute coronary syndrome and atrial fibrillation, antithrombotic therapy with oral anticoagulants significantly reduces the risk of major adverse cardiac events without increasing bleeding risk. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

June 29, 2022Frontiers in Cardiovascular MedicineOpen Access

Efficacy and Safety of Antithrombotic Therapy With Oral Anticoagulants in Real-World Elderly Patients With Acute Coronary Syndrome and Atrial Fibrillation

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Why the study?

The efficacy and safety of antithrombotic treatment with oral anticoagulants in elderly patients with acute coronary syndrome and atrial fibrillation are unclear.

Does oral anticoagulant therapy reduce major adverse cardiac events in elderly patients with acute coronary syndrome and atrial fibrillation?

Structured PICO

Does oral anticoagulant therapy reduce major adverse cardiac events in elderly patients with acute coronary syndrome and atrial fibrillation?

Population

548 hospitalized elderly patients (≥65 years of age, mean age 76 ± 6.6 years) diagnosed with acute coronary syndrome (ACS) and atrial fibrillation (AF) and treated with oral antithrombotic agents.

Intervention

Oral anticoagulants (OACs)

Comparator

No oral anticoagulant treatment (treated with other oral antithrombotic agents, more often receiving dual antiplatelet therapy)

Outcome

Major adverse cardiac events (MACEs), defined as a composite of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and systemic embolism at 1-year and 5-year follow-upcomposite

In real-world elderly patients with ACS and AF, oral anticoagulant therapy is associated with a significantly lower risk of ischemic events without increasing bleeding risk.

Implication

OAC was associated with lower MACE risk in elderly ACS-AF without excess bleeding; hypothesis-generating and should not change practice pending RCTs.

Abstract

Background The efficacy and safety of antithrombotic treatment with oral anticoagulants (OACs) in elderly patients with comorbidities of acute coronary syndrome (ACS) and atrial fibrillation (AF) are unclear. Methods A cohort of hospitalized elderly patients (≥65 years of age) diagnosed with ACS and AF and treated with oral antithrombotic agents were consecutively recruited. Follow-up was performed for at least 1 year. Major adverse cardiac events (MACEs) were defined as a composite of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and systemic embolism. The safety outcomes of bleeding were defined according to the Bleeding Academic Research Consortium (BARC) criteria. Results A cohort of 548 eligible patients (76 ± 6.6 years) was analyzed. Compared to the patients with OAC treatment ( n = 184, 33.6%), patients treated without OAC ( n = 364, 66.4%) were older, had a lower prevalence of persistent AF and unstable angina (UA), and more often presented with paroxysmal AF, acute myocardial infarction (AMI), stent implantation and dual antiplatelet therapy (DAPT). Compared to the patients without OAC treatment ( n = 364, 66.4%), patients treated with OAC ( n = 184, 33.6%) had a lower risk of MACEs at both the 1-year (4.3 vs. 15.1%, adjusted HR: 0.34, 95% CI: 0.15–0.80, p = 0.014) and 5-year (17.5 vs. 48.4%, adjusted HR: 0.36, 95% CI: 0.19–0.67, p = 0.001) follow-up. No significant difference was observed for bleeding events of BARC ≥2 between the groups (8.0 vs. 9.0%, adjusted HR: 1.17, 95% CI: 0.58–2.34, p = 0.667). Compared with warfarin-treated patients, the non-vitamin K antagonist oral anticoagulant-treated patients had lower risks of all-cause mortality (2.1 vs. 9.5%, HR: 0.18, 95% CI: 0.03–0.98, p = 0.047) and bleeding events of BARC ≥ 3 (2.1 vs. 4.8%, HR: 0.14, 95% CI: 0.02–1.10, p = 0.062). Conclusions Antithrombotic therapy with OACs in elderly patients with ACS and AF was associated with a lower risk of ischemic events without an increase in bleeding events. In real-world practice, the clinical awareness of anticoagulation treatments in elderly patients with ACS and AF needs to be strengthened.