title: Ischemic and bleeding events in patients with myocardial infarction undergoing percutaneous coronary intervention who require oral anticoagulation: Insights from the Canadian observational AntiPlatelet sTudy.
abstract: BACKGROUND
  Since the introduction of newer, more potent P2Y12 receptor inhibitors (P2Y12ris), practice patterns and associated clinical outcomes in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) and also requiring oral anticoagulation (OAC) have not been fully characterized.
  
  
  METHODS
  The Canadian Observational Antiplatelet Study was a prospective, multicenter, longitudinal, observational study (26 hospitals, December 2011 to May 2013) describing P2Y12ri treatment patterns and outcomes in patients with ST-elevation and non-ST-elevation MI undergoing PCI. We describe the clinical characteristics, treatment patterns, bleeding, and ischemic outcomes over the 15-month follow-up within and between the subgroups of patients discharged on either dual-antiplatelet therapy (DAPT) (acetyl salicylic acid [ASA]+P2Y12ri) or triple therapy (ASA+P2Y12ri+OAC).
  
  
  RESULTS
  Of the 2,034 patients at discharge, 86% (n = 1,757) were on DAPT, whereas 14% (n = 277) were on triple therapy (50% warfarin, 50% non-vitamin K OAC [NOAC]). The frequency of newer P2Y12ri use (prasugrel or ticagrelor) was similar in the DAPT and triple therapy groups (28% vs 26%, respectively). In the triple therapy group, NOAC use was higher in those receiving a new P2Y12ri compared to those receiving clopidogrel (75% vs 41%, respectively, P < .0001). The unadjusted and adjusted events of major cardiovascular event (MACE) and bleeding were higher in the triple therapy group. For patients on triple therapy, the bleeding or MACE events were not significantly different between those on clopidogrel versus those on ticagrelor or prasugrel.
  
  
  CONCLUSIONS
  In this observational study of MI patients requiring PCI, 1 in 8 were discharged on triple antithrombotic therapy, of whom 26% were on newer P2Y12ris. Patients on triple therapy had higher risk at baseline, with higher unadjusted and adjusted MACE and bleeding events compared to those on DAPT alone. Among triple therapy-treated patients, there was no difference in the MACE and bleeding events regardless of the P2Y12ri used.
authors.affiliation: St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Steven
authors.initials: S
authors.lastname: Sra
authors.affiliation: Canadian Heart Research Centre, Toronto, Ontario, Canada.
authors.forename: Mary K
authors.initials: MK
authors.lastname: Tan
authors.affiliation: Population Health Research Institute, Hamilton General Hospital, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Shamir R
authors.initials: SR
authors.lastname: Mehta
authors.affiliation: Eli Lilly Canada Inc., Toronto, Ontario, Canada.
authors.forename: Harold N
authors.initials: HN
authors.lastname: Fisher
authors.affiliation: Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, Quebec, Canada.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Déry
authors.affiliation: Mazankowski Alberta Heart Institute, University of Alberta, Canadian VIGOUR Centre, Edmonton, Alberta, Canada.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Welsh
authors.affiliation: Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Eisenberg
authors.affiliation: University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Overgaard
authors.affiliation: Eastern Health, Memorial University, St John's, Newfoundland and Labrador, Canada.
authors.forename: Barry F
authors.initials: BF
authors.lastname: Rose
authors.affiliation: Royal Jubilee Hospital and Victoria Heart Institute, Victoria, British Columbia, Canada.
authors.forename: Anthony J Della
authors.initials: AJ
authors.lastname: Siega
authors.affiliation: St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Asim N
authors.initials: AN
authors.lastname: Cheema
authors.affiliation: Health Sciences North, Sudbury, Ontario, Canada.
authors.forename: Brian Y L
authors.initials: BY
authors.lastname: Wong
authors.affiliation: Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Henderson
authors.affiliation: New Brunswick Heart Centre, CardioVascular Research NB, Saint John, New Brunswick, Canada.
authors.forename: Sohrab
authors.initials: S
authors.lastname: Lutchmedial
authors.affiliation: London Health Sciences Centre, Western University, London, Ontario, Canada.
authors.forename: Shahar
authors.initials: S
authors.lastname: Lavi
authors.affiliation: St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, Toronto, Ontario, Canada. Electronic address: goodmans@chrc.net.
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
authors.affiliation: St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Yan
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy / Q000628:therapy*; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D011446:Prospective Studies; D058921:Purinergic P2Y Receptor Antagonists / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists