Safety of Combining New Anticoagulant Agents and Dual Antiplatelet Therapy

Atrial fibrillation is the most common arrhythmia and its combination with a history of acute myocardial infarction or coronary angioplasty is quite frequent.

According to this study (recently published in JACC), in a real-world population, the combination of direct anticoagulant agents and dual antiplatelet therapy reduces significantly the risk of bleeding and provides similar thromboembolic protection compared with vitamin K antagonists combined with dual antiplatelet therapy.

The authors investigated the risk of bleeding, ischemic stroke, acute myocardial infarction, and all-cause mortality associated with new direct anticoagulant agents compared with vitamin K antagonists in combination with aspirin, clopidogrel, or both in patients with atrial fibrillation and prior infarction or coronary angioplasty.

Read also: Surprises in the Physiopathology of Critical Ischemia.

Overall, 3222 patients between 2011 and 2017 were included in this study and followed for 12 months until an outcome, study end, or death.

Among them, 875 (27%) were treated with a vitamin K inhibitor plus single antiplatelet therapy, 595 (18%) were treated with direct anticoagulant agents plus single antiplatelet therapy, 1,074 (33%) were treated with a vitamin K inhibitor plus dual antiplatelet therapy, and 678 (22%) were treated with a direct anticoagulant agent plus dual antiplatelet therapy.

At 3 months, there was a significant difference in the risk of acute myocardial infarction associated with direct anticoagulant agents plus single antiplatelet therapy compared with vitamin K inhibitors plus single antiplatelet therapy (absolute risk difference: 1.53), with no difference regarding bleeding, ischemic stroke, and all-cause mortality.

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Comparing a vitamin K inhibitor plus dual antiplatelet therapy vs. direct anticoagulant agents plus dual antiplatelet therapy, there was a significant reduction in bleedings (absolute risk difference: 1.96), even though mortality, stroke, and infarction rates remained similar for both strategies.

Conclusion

In a real-world population with atrial fibrillation receiving antiplatelet therapy due to prior infarction or coronary angioplasty, direct anticoagulant agents combined with dual antiplatelet therapy decreased the risk of bleeding without raising the thromboembolic risk, compared with vitamin K inhibitors and dual antiplatelet therapy.

Original title: Combining Oral Anticoagulants with Platelet Inhibitors in Patients with Atrial Fibrillation and Coronary Disease.

Reference: Caroline Sindet-Pedersen et al. J Am Coll Cardiol 2018;72:1790-800.

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