title: Antithrombotic therapy after coronary stenting in patients with nonvalvular atrial fibrillation.
abstract: BACKGROUND
  The safety and efficacy of triple therapy (TT; warfarin with dual antiplatelet therapy [DAPT]) in post-percutaneous coronary intervention (PCI) patients with atrial fibrillation (AF) are unclear. We aimed to determine whether TT is associated with a decreased stroke rate and an acceptable bleeding rate in this population.
  
  
  METHODS
  This was a single-centre, retrospective study. Primary composite outcome was death, ischemic stroke, or transient ischemic attack. Secondary outcomes included components of primary outcome, bleeding, and blood transfusion rates.
  
  
  RESULTS
  Of 602 post-PCI patients with AF between 2000 and 2009, 382 received TT, 220 DAPT. Mean follow-up post PCI was 5.9 ± 5.0 months. The TT group had a higher CHADS(2) score (2.6 vs 2.1, P < 0.001), older age (72.9 vs 70.5 years, P = 0.039), more heart failure (72.3% vs 36.9%, P = 0.010), and more strokes (14.4% vs 6.4%, P = 0.010). Neither primary outcome, major bleeding, nor blood transfusion rates differed between treatment groups, but more gastrointestinal bleeding occurred with TT use (2.6% vs 0.5%, P = 0.045). Net clinical benefit was -5.2 (CHADS(2) ≤ 2), 0.9 (CHADS(2) > 2), and -3.2 (overall) per 100 patient-years.
  
  
  CONCLUSIONS
  Although we found no association with TT usage and a reduction in cerebrovascular ischemic or major bleeding events in post-PCI patients with AF regardless of CHADS(2) score vs DAPT, the study was likely underpowered to demonstrate a clinically relevant reduction. TT was associated with a 5-fold increase in gastrointestinal bleeding vs DAPT. Net clinical benefit calculations suggest benefits of TT in patients with CHADS(2) > 2. Stratification with CHADS(2) might be useful to determine the optimal antithrombotic therapy post PCI.
authors.affiliation: Interventional Cardiology Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Kay W
authors.initials: KW
authors.lastname: Ho
authors.forename: Joan
authors.initials: J
authors.lastname: Ivanov
authors.forename: Xavier
authors.initials: X
authors.lastname: Freixa
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Overgaard
authors.forename: Mark D
authors.initials: MD
authors.lastname: Osten
authors.forename: Douglas
authors.initials: D
authors.lastname: Ing
authors.forename: Eric
authors.initials: E
authors.lastname: Horlick
authors.forename: Karen
authors.initials: K
authors.lastname: Mackie
authors.forename: Peter H
authors.initials: PH
authors.lastname: Seidelin
authors.forename: Vladimír
authors.initials: V
authors.lastname: Džavík
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000150:complications*; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D017202:Myocardial Ischemia / Q000150:complications / Q000601:surgery*; D009864:Ontario / Q000453:epidemiology; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods*; D019106:Postoperative Hemorrhage / Q000139:chemically induced / Q000453:epidemiology; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*
chemical_list: D005343:Fibrinolytic Agents