Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis.

Acute Coronary Syndrome / complications Administration, Oral Anticoagulants / administration & dosage Atrial Fibrillation / complications Cardiovascular Diseases / epidemiology Drug Therapy, Combination Hemorrhage / chemically induced Humans Platelet Aggregation Inhibitors / adverse effects Retrospective Studies United States / epidemiology Warfarin / administration & dosage

Journal

American heart journal
ISSN: 1097-6744
Titre abrégé: Am Heart J
Pays: United States
ID NLM: 0370465

Informations de publication

Date de publication:
12 2021
Historique:
received: 01 04 2021
accepted: 18 08 2021
pubmed: 28 8 2021
medline: 29 12 2021
entrez: 27 8 2021
Statut: ppublish

Résumé

Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF). To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF. Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019. New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis. Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time. After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72). Residual confounding. In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.

Sections du résumé

BACKGROUND
Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF).
OBJECTIVE
To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF.
DESIGN
Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019.
PARTICIPANTS
New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis.
MEASUREMENTS
Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time.
RESULTS
After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72).
LIMITATIONS
Residual confounding.
CONCLUSIONS
In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.

Identifiants

DOI: 10.1016/j.ahj.2021.08.014 PMID: 34450051
pubmed: 34450051
pii: S0002-8703(21)00212-X
doi: 10.1016/j.ahj.2021.08.014
pii:
doi:

Substances chimiques

Anticoagulants 0
Platelet Aggregation Inhibitors 0
Warfarin 5Q7ZVV76EI

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

71-81

Informations de copyright

Copyright © 2021 Elsevier Inc. All rights reserved.

Auteurs

Ghadeer K Dawwas (GK)

Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA. Electronic address: gkdawwas@pennmedicine.upenn.edu.

Geoffrey D Barnes (GD)

Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MICH.

Eric Dietrich (E)

Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, MIA.

Adam Cuker (A)

Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Charles E Leonard (CE)

Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.

Michael V Genuardi (MV)

Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

James D Lewis (JD)

Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

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Classifications MeSH

questionsmedicales.fr › Maladies cardiovasculaires › Maladies vasculaires › Ischémie myocardique › Syndrome coronarien aigu › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Thérapeutique › Traitement médicamenteux › Voies d'administration de substances chimiques et des médicaments › Administration par voie orale › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Actions chimiques et utilisations › Actions pharmacologiques › Utilisations thérapeutiques › Agents hématologiques › Anticoagulants › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › États, signes et symptômes pathologiques › Processus pathologiques › Troubles du rythme cardiaque › Fibrillation auriculaire › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Maladies cardiovasculaires › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Thérapeutique › Traitement médicamenteux › Association de médicaments › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › États, signes et symptômes pathologiques › Processus pathologiques › Hémorragie › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Eucaryotes › Animaux › Chordés › Vertébrés › Mammifères › Eutheria › Primates › Haplorhini › Catarrhini › Hominidae › Humains › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Actions chimiques et utilisations › Actions pharmacologiques › Utilisations thérapeutiques › Agents hématologiques › Antiagrégants plaquettaires › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Méthodes épidémiologiques › Caractéristiques des études épidémiologiques › Études épidémiologiques › Études de cohortes › Études rétrospectives › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Régions géographiques › Amériques › Amérique du Nord › États-Unis › Cardiovascular and major bleeding outcomes...
questionsmedicales.fr › Composés hétérocycliques › Composés hétérocycliques à cycles fusionnés › Composés hétérobicycliques › Benzopyranes › Coumarines › 4-Hydroxycoumarines › Warfarine › Cardiovascular and major bleeding outcomes...