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Antithrombotic strategies in elderly patients with atrial fibrillation revascularized with drug-eluting stents: PACO-PCI (EPIC-15) registry

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    Jose M. de la Torre Hernandez
    Correspondence
    Corresponding author at: Unidad de Hemodinámica y Cardiología Intervencionista, Hospital Universitario Marqués de Valdecilla, Valdecilla Sur, 1a Planta, Santander 39008, Spain.
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    1 All these authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
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    Cardiology Dpt., Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
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    José L. Ferreiro
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    Cardiology Dpt., Hospital Universitario de Bellvitge - IDIBELL, CIBER-CV, L'Hospitalet de Llobregat, Barcelona, Spain
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    Ramon Lopez-Palop
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    Cardiology Dpt., Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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    Soledad Ojeda
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    Cardiology Dpt., Hospital Universitario Reina Sofía, University of Córdoba, Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Cordoba, Spain
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    David Marti
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    Cardiology Dpt., Hospital Universitario Central de la Defensa Gómez Ulla, Madrid, Spain
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    Pablo Avanzas
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    Cardiology Dpt., Hospital Universitario Central de Asturias, Department of Medicine, University of Oviedo, Oviedo, Spain
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    Jose A. Linares
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    Cardiology Dpt., Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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    Alejandro Diego
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    Cardiology Dpt., Hospital Clínico Universitario de Salamanca, Salamanca, Spain
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    Ignacio J. Amat
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    Cardiology Dpt., Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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    Miren Telleria
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    Cardiology Dpt., Hospital Donostia, San Sebastián, Spain
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    Belen Cid
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    Complejo Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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    Imanol Otaegui
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    Cardiology Dpt., Hospital Vall d'Hebron, Barcelona, Spain
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    Iñigo Lozano
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    Cardiology Dpt., Hospital de Cabueñes, Gijon, Spain
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    David Serrano
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    Cardiology Dpt., Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
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    Eduardo Pinar
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    Cardiology Dpt., Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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    Rafael González-Manzanares
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    Cardiology Dpt., Hospital Universitario Reina Sofía, University of Córdoba, Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Cordoba, Spain
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    Ricardo Concepción-Suárez
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    Cardiology Dpt., Hospital Universitario Central de la Defensa Gómez Ulla, Madrid, Spain
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    Isaac Pascual
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    Cardiology Dpt., Hospital Universitario Central de Asturias, Department of Medicine, University of Oviedo, Oviedo, Spain
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    Cristobal Urbano
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    Cardiology Dpt., Hospital Regional Universitario de Málaga, Malaga, Spain
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    Mario Sadaba
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    Cardiology Dpt., Hospital de Galdakao, Galdakao, Spain
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    Marcos Garcia-Guimaraes
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    Cardiology Dpt., Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
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    Joan F. Andres-Cordon
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    Cardiology Dpt., Hospital Germans Trias i Pujol, Badalona, Spain
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    Felipe Hernandez
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    Cardiology Dpt., CUN Madrid-Pamplona, Madrid, Spain
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    Angel Sanchez-Recalde
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    Cardiology Dpt., Hospital Ramon y Cajal, Madrid, Spain
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    Celia Garilleti
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    Cardiology Dpt., Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
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    Armando Perez de Prado
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    Cardiology Dpt., Complejo Asistencial Universitario de León, Leon, Spain
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  • Author Footnotes
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      Highlights

      • Evidence regarding combination of antithrombotic agents in elderly patients with AF undergoing DES implantation is scarce.
      • Randomized trials focused on elderly patients are hardly foreseeable, so large registries are required to enhance knowledge.
      • This large multicenter registry provides valuable insights into the contemporary practice in this complex scenario.
      • Triple strategy dominates, but beyond 1 month or without Apixaban bleeding was increased without additional MACCE prevention.
      • Double therapy reduces risk of bleeding but with a trade-off in terms of ischemic cardiac events in a high-risk population.

      Abstract

      Background

      We sought to investigate the antithrombotic regimens applied and their prognostic effects in patients over 75 years old with atrial fibrillation (AF) after revascularization with drug-eluting stents (DES).

      Methods

      Retrospective registry in 20 centers including patients over 75 years with AF treated with DES. A primary endpoint of MACCE and a co-primary endpoint of major bleeding by ISTH criteria were considered at 12 months.

      Results

      A total of 1249 patients (81.1 ± 4.2 years, 33.1% women, 66.6% ACS, 30.6% complex PCI) were included. Triple antithrombotic therapy (TAT) was prescribed in 81.7% and dual antithrombotic therapy (DAT) in 18.3%. TAT was based on direct oral anticoagulants (DOAC) in 48.4% and maintained for only 1 month in 52.2%, and DAT included DOAC in 70.6%. Primary endpoint of MACCE was met in 9.6% and primary endpoint of major bleeding in 9.4%. TAT was significantly associated with more bleeding (10.2% vs. 6.1%, p = 0.04) but less MACCE (8.7% vs. 13.6%, p = 0.02) than DAT and the use of DOAC was significantly associated to less bleeding (8% vs. 11.1%, p = 0.03) and similar MACCE (9.8% vs. 9.4%, p = 0.8). TAT over 1 month or with VKA was associated with more major bleeding but comparable MACCE rates.

      Conclusions

      Despite advanced age TAT prevails, but duration over 1 month or the use of other agent than Apixaban are associated with increased bleeding without additional MACCE prevention. DAT reduces bleeding but with a trade-off in terms of ischemic events. DOAC use was significantly associated to less bleeding and similar MACCE rates.

      Keywords

      Abbreviations and acronyms:

      AF (atrial fibrillation), DAT (dual antithrombotic therapy), DES (drug-eluting stents), DOAC (direct oral anticoagulants), MACCE (major adverse cardiovascular and cerebrovascular events), PCI (percutaneous coronary intervention), TAT (triple antithrombotic therapy), VKA (vitamin-K antagonists)
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      Linked Article

      • Antithrombotic therapy in the elderly: The more we know, the more we can offer
        International Journal of CardiologyVol. 339
        • Preview
          Atrial fibrillation (AF) and coronary artery disease commonly co-exist in elderly patients [1]. While long-term oral anticoagulation therapy is needed to prevent stroke and systemic embolism, antiplatelet agents are recommended to reduce the risk of coronary thrombotic events in this patient population [2]. Elderly patients are prone to both an increased risk of bleeding and of thrombotic events [3,4]. Therefore, keeping a favorable balance between ischemic and hemorrhagic risks in this growing population represents a major challenge in clinical practice.
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