Impact of recommendations of guidelines in patients with atrial fibrillation submitted coronary stenting
IMPACT OF RECOMMENDATIONS OF GUIDELINES IN PATIENTS WITH ATRIAL FIBRILLATION SUBMITTED CORONARY STENTING María Mutuberria, Antonia Sambola, Eduard Bosch, Bruno García del Blanco, F. Alfonso, A.Cequier, Hector Bueno, O. Rodriguez, Jose Antonio Barrabés, Pilar Tornos, Nadia Llavero, David Garcia Dorado. Àrea del Cor. Hospital Universitario Vall d´Hebrón. Barcelona. Spain.
INTRODUCTION:Atrial fibrillation (AF) is the most commonsustained cardiac arrhythmia.-Increasing with age. Arch Intern Med 1995;155:469–73It is a major contributor to stroke and thromboembolism. Guidelines consider specific stroke scores: AHA 2011: CHADS2. ESC 2010: CHA2DS2VASc.
A particularly challenging situation…Patients with AF presenting with an ACS/undergoing PCI-S. PCI-S: Percutaneous Coronary Intervention and Stent implantation. Antithrombotic therapy in AF and ACS/PCI-S:- No prospective randomized trials have been reported addressing this issue.- The optimal treatment for these patients according to different levels ofthromboembolic risk is nowadays undefined.- Current guidelines recommendations are based on consensus documents,retrospective studies and expert´s opinion.
OBJECTIVE:The purpose of this study was to assess the impact of tripletherapy (TT) in rates of thromboembolism and bleeding inpatients with non-valvular AF submitted to stenting, regardingthe use of CHADS2 and CHA2DS2VASc scores.
METHODS:- Retrospective multicenter study, from 2007 to 2011.- Population: patients with non-valvular AF undergoing PCI-S.- Exclusion criteria: life expectancy < 3 months, impossibility of follow-up.Recorded data during admission: - Patients clinical characteristics - CHADS2 score - CHA2DS2VASc score - PCI details (at attending interventional cardiologist discretion). - Antithrombotic therapy at discharge (at attending clinician discretion).After discharge… check medication and complications.
METHODS-2: - Major bleeding: - Hb drop ≥ 4 g/dl, requiring transfusion of ≥2 IU of blood or corrective surgery. - Cerebral haemorrhage or retroperitoneal haemorrhage. - Cardiovascular events: CV death, acute myocardial infarction, target vessel failure, stroke/peripheral thromboembolism, or stent thrombosis.Follow-up: 1 year Recorded events:Primary end points: Secondary end points:Efficacy: Safety:Thromboembolism/stroke Major bleedings MAE:MACE: - MACE - Death - Thromboembolism - Acute Myocardial Infarction - Major Bleeding - Target vessel failure (TVF) ITT
RESULTS: CHADS2 ≥ 2 59.3% CHA2DS2VASc ≥ 2 74.6% TT DAPT N=307; 62.8% N=182; 37.2% p value Age, y 76.0 ± 7.2 72.8 ± 7.7 0.016 Sex (Female) 25.8% 24.2% 0.585489 patients with non- CHADS2 ≥ 2 64.8 % 35.2% 0.17 valvular AF + PCI-S. CHA2DS2VASc ≥ 2 64.3% 35.2% 0.25 p=0.08 p=0.37 p=0.02 p=0.09 p=0.44 p=0.45 p=0.15
RESULTS-5:MORTALITY: 44 patients (9.2%) died during follow up. Bleeding events 13 (29.2%) Thromboembolic events 6 (13.6%) Sudden death 6 (13.4%) Cardiogenic shock/HF 18 (41%) Others 1 (2.3%) Bleeding events 13 (29.2%) Hemorrhagic stroke 5 (11.3%) Thromboembolic events 6 (13.6%) Gastrointestinal bleeding 2 (4.5%) ACS 1 (2.3%) Tamponade 1 (2.3%) Stent thrombosis 2 (4.5%) CABG 2 (4.5%) Ischemic stroke 3 (6.8%) Traumatic brain injury 3 (6.8%) 4 of them had high stroke risk 3 of them had low stroke risk (CHADS2: ≥ 2). (CHADS2: 1).
RESULTS-6: Multivariate analysis: OR p value Age 1.03 (95% CI 0.96-1.1) 0.42 HTA 2.17 (95% CI 0.37-12.4) 0.38 DM 0.98 (95% CI 0.33-2.89) 0.97 Renal failure 1.48 (95% CI 0.98-2.22) 0.06 CHADS2 1.86 (95% CI 0.93-1.77) 0.076 Previous stroke 5.7 (95% CI 1.0-34) 0.05 DES 0.35 (95% CI 0.13-0.96) 0.03 Triple therapy (TT) 0.35 (95% CI 0.12-0.98) 0.05
CONCLUSIONS:In real life, in patients with non-valvular AF undergoing PCI-S, thedecision of treatment with DAPT or TT is not always influenced byCHADS2 or CHA2DS2VASc.TT is underused in patients with high thromboembolic risk, whichresults in an increased rate of stroke.TT in patients with low thromboembolic risk shows a tendencytowards more bleeding events without apparent potential benefitcomparing DAPT.
CONCLUSION:Our results illustrate how, in real clinical practice, theadherence to guidelines for anticoagulation have benefitialeffects on the outcomes in patients with atrial fibrillation,stressing the importance of the routinary implementation ofguidelines.
Efficacy and safety of DAPT compared with TT. MUSICA-2 STUDY.Patients in AF with low-moderate thromboembolic risk (CHADS2≤2) submitted to PCI-S Sample size: 304 patients Design: multicentric, randomized, open-label Randomization BMS 6 weeks DES 6 months OAC ASA 300 mg/day ASA 100 mg/day Clopidogrel 75 mg/day Clopidogrel 75 mg/day Primary outcome: cardiovascular events. Secondary outcome: major bleedings.