1 R1 임준욱 Anticoagulant and Antiplatelet Therapy Use in 426 Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention and Stent Implantation Implications for Bleeding Risk and Prognosis JACC Feb.

2 BACKGROUND  Atrial fibrillation (AF) - the most common cardiac arrhythmia, association with stroke and thromboembolism.->anticoagulation with coumarins.  A management problem - long-term anticoagulation with coumarins is recommended as thromboprophylaxis because AF subsequently presents with ACS or PCI - > more bleeding complications.  A lack of published evidence on the optimal antithrombotic management strategy.  Objective - present a case series of 426 patients with AF undergoing PCI with particular attention to clinical and demographic characteristics of the patients, stroke risk factors....

3  A retrospective 2-center registry analysis.  AF that underwent PCI with at least 1 stent implanted over a 5-year period (January 2001 to December 2006); all of the outcome data  Permanent, persistent,or paroxysmal AF and those who developed newonset AF during their current admission were included in this analysis.  End point definitions - primary end point: defined as the occurrence of MACE(death,MI, or target vessel revascularization.) - secondary safety end point - major adverse events (MAE) (any MACE, major bleeding complications, and/or stroke during the follow-up period. ) METHODS

4  Statistical analysis  Continuous variables : Kolmogorov-Smirnov test.  The comparison of discrete variables : the chi-square test  Comparisons of the groups for continuous variables :unpaired t test  Survival analyses : Kaplan-Meier analysis, the log-rank test  Etc.: stepwise Cox proportional hazard model analysis METHODS

5 RESULTS

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7 5.6% 3.6% RESULTS

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10 no anticoagulation use at discharge anticoagulation use at discharge

11 RESULTS

12 RESULTS

13  Patients with AF undergoing PCI with stenting. - represent a high-risk population owing to age,comorbidities, and the presence of stroke risk factors, as well as the relatively high incidence of acute coronary syndromes.  The protective effect of the coumarins in patients with AF treated with PCI/stents - decrease the incidence of MACE.  Age, nontreatment with coumarins – independent predictors of MACE  Patients with AF treated with PCI/stents who have a low risk of bleeding complications - ‘ triple-therapy’ regimen should be the elective antithrombotic drug treatment approach.  Coumarins plus aspirin after PCI < ticlopidine plus aspirin in preventing stent thrombosis  Oral anticoagulation > dual antiplatelet therapy in stroke prevention => explain why triple therapy has been commonly used.  Triple-therapy => increases the risk of bleeding. DISCUSSIO N

14  Duration - varied widely due to the use of DES(clopidogrel between 6 and 12months,bare-metal stents,1 month)  “A recent meta - analysis with estimates of risk and benefit of coumarins plus aspirin after myocardial infarction” - at low or intermediate risk for bleeding, the cardiovascular benefits of coumarins outweigh the bleeding risks.  Triple antithrombotic therapy - associated with a 7% major bleeding risk.  DES - used in 40.1% of the patients and more frequently in diabetic patients.  A multivariate analysis - there was no significant difference in the incidence of MACE.  Prolonged dual antiplatelet administration & higher rate of stent thrombosis – DES should probably be discouraged in anticoagulated AF. DISCUSSIO N

15  Limitation of This study - not a randomized controlled trial - the changes of antithrombotic regiment in these patients during the follow-up period.-> relation to the presence of thrombotic or hemorrhagic complications.  Treatment with coumarins at discharge - shows a beneficial effect on prognosis by reducing the incidence of death and MACE, and such benefits do not appear to be associated with a substantial increase in major bleeding events.  Further large studies are required to assess the bleeding and thrombotic risk with various post-PCI strategies in patients with AF to facilitate the development of guidelines. DISCUSSIO N