Key result
In patients on oral anticoagulants undergoing PCI, the 30-day rate of thrombotic events was not significantly different between those treated with NOACs (2.0%) versus VKAs (4.5%).
Why the study?
Triple therapy increases bleeding in patients on OACs undergoing PCI, and the use of NOACs and stronger P2Y12 inhibitors has increased, prompting investigation into antithrombotic management over time.
Does dual therapy or NOAC use reduce thrombotic and bleeding events compared to triple therapy or VKAs in patients on oral anticoagulants undergoing PCI?
Cohort (n=758)
Yes
Does dual therapy or NOAC use reduce thrombotic and bleeding events compared to triple therapy or VKAs in patients on oral anticoagulants undergoing PCI?
In real-world practice, dual therapy with a NOAC and clopidogrel has increasingly become the preferred strategy for patients on oral anticoagulants undergoing PCI, demonstrating comparable 30-day safety and efficacy to triple therapy and VKAs.
Answers are grounded in this paper and cite their sources.
Supports shift toward NOAC-based dual therapy in anticoagulated PCI patients; leaves open confirmation by randomized trials.
BACKGROUND: Patients on oral anticoagulants (OACs) undergoing percutaneous coronary intervention (PCI) also require aspirin and a P2Y12 inhibitor (triple therapy). However, triple therapy increases bleeding. The use of non-vitamin K antagonist oral anticoagulants (NOACs) and stronger P2Y12 inhibitors has increased. The aim of our study was to gain insight into antithrombotic management over time. METHODS: A prospective cohort study of patients on OACs for atrial fibrillation or a mechanical heart valve undergoing PCI was performed. Thrombotic outcomes were myocardial infarction, stroke, target-vessel revascularisation and all-cause mortality. Bleeding outcome was any bleeding. We report the 30-day outcome. At discharge, 47% were on vitamin K antagonists (VKAs), 52% on NOACs, 43% on triple therapy and 54% on dual therapy. Treatment with a NOAC plus clopidogrel increased from 14% in 2014 to 67% in 2019. The rate of thrombotic (4.5% vs 2.0%, p = 0.06) and bleeding (17% vs. 14%, p = 0.42) events was not significantly different in patients on VKAs versus NOACs. Also, the rate of thrombotic (2.9% vs 3.4%, p = 0.83) and bleeding (18% vs 14%, p = 0.26) events did not differ significantly between patients on triple versus dual therapy. CONCLUSIONS: Patients on combined oral anticoagulation and antiplatelet therapy undergoing PCI are elderly and have both a high bleeding and ischaemic risk. Over time, a NOAC plus clopidogrel became the preferred treatment. The rate of thrombotic and bleeding events was not significantly different between patients on triple or dual therapy or between those on VKAs versus NOACs.
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Veer et al. (2022) conducted a cohort in Atrial fibrillation or mechanical heart valve undergoing percutaneous coronary intervention (n=758). Non-vitamin K antagonist oral anticoagulants (NOACs) vs. Vitamin K antagonists (VKAs) was evaluated on Composite of myocardial infarction, ischaemic stroke, target-vessel revascularisation, and all-cause mortality at 30 days (p=0.062). In patients on oral anticoagulants undergoing PCI, the 30-day rate of thrombotic events was not significantly different between those treated with NOACs (2.0%) versus VKAs (4.5%).
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