Original Title: Outcomes of Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention Receiving an Oral Anticoagulant and Dual Antiplatelet Therapy, a Comparison of Clopidogrel vs. Prasugrel from the TRANSLATE-ACS Study. Reference: Jackson L.R. et al. JACC Cardiovasc Interv. 2015 Dec 21;8(14):1880-9.
Courtesy of Dr Agustín Vecchia.
In these last years, new and more powerful antiaggregants have given relevance to the discussion over the management of patients that need a triple scheme (oral anticoagulant, + dual antiplatelet therapy).
The 2014 European guidelines do not recommend prasugrel or ticagrelor for patients that need a triple antithrombotic scheme (Class III). 5 to10% of patients require oral anticoagulation at the time of PCI and there is not enough evidence to determine their best management, which remains unanswered.
The present study seeks to compare bleeding rates depending to which P2Y12 inhibitor is used in AMI patients undergoing PCI with stent placement. It includes patients from the TRANSLATE-ACS (n=12365), a prospective observational registry carried out in 233 centers in USA, patients with and without ST elevation MI treated with PCI and receiving dual antiaggregation therapy. Propensity score matching, bleeding rates were compared at 6 months using BARC score. Patients were stratified according to whether bleeding events were associated to hospitalization and in relation to the treatment they received: AAS+ anticoagulant + clopidogrel (triple-C), AAS + anticoagulant + prasugrel (triple-P), AAS + clopidogrel (dual-C) or AAS + prasugrel (dual-P).
From a total 11756 AMI patients, 526 (4.5%) were discharged with triple-C, 91 (0.8%) with triple-P, 7715 (66%) with dual-C, and 3424 (29%) with dual-P. Patients in the triple scheme had a significantly higher BARC bleeding rate (28.7% vs 19.7%; p=0.0001). The triple-P scheme was associated with a higher rate of any BARC bleeding compared to the triple-C scheme (39.0% vs 24.4% RR adjusted 2.37 (1.36–4.15) p=0.003). This difference was at the expense of bleeding events reported by patients that did not required hospitalization. There were no significant differences between triple-C and triple-P schemes when comparing bleeding events that required hospitalization (7.8% vs. 7.8%; RR adjusted 0.62; p=0.4127).
Conclusion
In AMI patients, adding anticoagulant to the dual antiplatelet therapy significantly increased bleeding, regardless the dual antiaggregation therapy. In patients under the triple scheme, those treated with prasugrel had higher bleeding rates reported by patients but no bleeding events required hospitalization.
Editorial Comment
The following observational study adds new information to the heated debate about post PCI triple antithrombotic schemes.
As regards the employed anticoagulant, 93% of patients received warfarin (this makes sense considering there is no evidence as regards NOACs in these scenarios). The use of NOACs is being assessed in 3 ongoing studies.
Follow up starts at discharge, which means in-hospital bleeding events are being excluded. Surprisingly, only 1 patient out of 91 treated with triple-P presented moderate/severe GUSTO bleeding.
Given the fact that patients with anticoagulants are more prone to be discharged with clopidogrel, we should bear in mind this registry may be biased. In addition, the number of patients with triple-P is small, limiting the possibility to adjust results.
Courtesy of Dr Agustín Vecchia.