Thrombocytopenia as a Bleeding Risk Factor in Atrial Fibrillation and Coronary Artery Disease: Insights From the AFIRE Study

Raisuke Iijima; Masahide Tokue; Masato Nakamura; Satoshi Yasuda; Koichi Kaikita; Masaharu Akao; Junya Ako; Tetsuya Matoba; Katsumi Miyauchi; Nobuhisa Hagiwara; Kazuo Kimura; Atsushi Hirayama; Kunihiko Matsui; Hisao Ogawa

doi:10.1161/jaha.123.031096

October 10, 2023Journal of the American Heart AssociationOpen Access

Thrombocytopenia as a Bleeding Risk Factor in Atrial Fibrillation and Coronary Artery Disease: Insights From the AFIRE Study

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Why the study?

Whether thrombocytopenia increases the bleeding risk in patients with atrial fibrillation and chronic coronary syndrome remains unclear.

Does thrombocytopenia increase the risk of major bleeding and ischemic events in patients with atrial fibrillation and chronic coronary syndrome?

Structured PICO

Does thrombocytopenia increase the risk of major bleeding and ischemic events in patients with atrial fibrillation and chronic coronary syndrome?

P

Population

2,133 patients with atrial fibrillation and stable coronary artery disease (chronic coronary syndrome) from the AFIRE trial.

I

Intervention

Thrombocytopenia (defined as platelet count <100,000/mm³ at enrollment)

C

Comparator

Nonthrombocytopenia

O

Outcome

Incidence of major bleeding based on the International Society on Thrombosis and Hemostasis criterion and major adverse cardiovascular ischemic events (cardiac death, myocardial infarction, and stroke)safety

In patients with atrial fibrillation and chronic coronary syndrome, baseline thrombocytopenia is an independent predictor of major bleeding, emphasizing the need for careful selection of antithrombotic therapy.

Implication

May warrant extra caution with combination therapy in this subset; leaves open whether platelet count should refine bleeding-risk scores.

Abstract

Background Thrombocytopenia poses a risk of bleeding in patients with chronic coronary syndrome after coronary intervention. However, whether thrombocytopenia also increases the bleeding risk in patients with atrial fibrillation and chronic coronary syndrome remains unclear. Methods and Results This study evaluated the AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial. Thrombocytopenia was defined as platelet count <100 000/mm 3 level at enrollment. Primary end points included incidence of major bleeding based on the International Society on Thrombosis and Hemostasis criterion and major adverse cardiovascular ischemic events (cardiac death, myocardial infarction, and stroke). A total of 2133 patients were classified into the thrombocytopenia (n=70) and nonthrombocytopenia (n=2063) groups. Major bleeding was significantly higher in the thrombocytopenia group than in the nonthrombocytopenia group (10.0% versus 4.1%, P =0.027). The thrombocytopenia group tended to have a higher risk of major adverse cardiovascular ischemic events (11.4% versus 6.2%, P =0.08). The bleeding incidence was significantly higher in patients with thrombocytopenia receiving combination therapy with rivaroxaban and a single antiplatelet drug (thrombocytopenia group, 14.3%, versus nonthrombocytopenia group, 5.0%; hazard ratio, 3.18 [95% CI, 1.27–7.97], P =0.014). Thrombocytopenia was an independent predictor of major bleeding (hazard ratio, 2.57 [95% CI, 1.19–5.56], P =0.017). Conclusions Among patients with atrial fibrillation and chronic coronary syndrome, thrombocytopenia was significantly associated with increased risk of major bleeding. Selecting drugs for patients with thrombocytopenia continuing antithrombotic therapy should be given special consideration. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02642419. https://www.umin.ac.jp/ctr/ ; Unique identifier: UMIN000016612.