Dabigatran versus vitamin k antagonist: an observational across‐cohort comparison in acute coronary syndrome patients with atrial fibrillation

• Published in: Journal of thrombosis and haemostasis 2018-03, Vol.16 (3), p.465-473
• Main Authors: Gaubert, M., Resseguier, N., Laine, M., Bonello, L., Camoin‐Jau, L., Paganelli, F.
• Format: Article
• Language: English
• Subjects: acute coronary syndrome; Acute Coronary Syndrome - complications; Acute Coronary Syndrome - drug therapy; Acute coronary syndromes; Administration, Oral; Aged; Aged, 80 and over; Anticoagulants - administration & dosage; Aspirin; Aspirin - administration & dosage; atrial fibrillation; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Bacteriology; Bleeding; Blood Platelets - cytology; Cardiac arrhythmia; Cardiology and cardiovascular system; Clopidogrel; Clopidogrel - administration & dosage; Cohort Studies; Confidence intervals; Coronary Angiography; Dabigatran - administration & dosage; Female; Fibrillation; Glomerular Filtration Rate; Hemorrhage - prevention & control; Human health and pathology; Humans; Incidence; Infectious diseases; Ischemia; Kaplan-Meier Estimate; Life Sciences; Male; Microbiology and Parasitology; Middle Aged; oral thrombin inhibitor; Outcome Assessment (Health Care); Patient Safety; Phenindione - administration & dosage; Phenindione - analogs & derivatives; Propensity Score; Proportional Hazards Models; Risk; Thrombin; Treatment Outcome; Vitamin K; Vitamin K - antagonists & inhibitors; vitamin K antagonist
• ISSN: 1538-7933; 1538-7836; 1538-7836
• DOI: 10.1111/jth.13931

Essentials Acute coronary syndrome (ACS) with atrial fibrillation (AF) is a therapeutic challenge. Dual and triple antithrombotic therapy showed a similar thrombotic risk in ACS patients with AF. The omission of aspirin during the first month did not increase the rate of ischemic events. Replacement of vitamin K antagonist by dabigatran leads to an increased thrombotic risk. Summary Background Dual antithrombotic therapy comprising a vitamin K antagonist (VKA) plus clopidogrel reduces the incidence of major bleeding compared with triple therapy (VKA + clopidogrel + aspirin) in acute coronary syndrome (ACS) patients with atrial fibrillation (AF), with a similar thrombotic risk. The oral thrombin inhibitor dabigatran (150 mg twice a day) showed superiority over VKA in non‐valvular AF, but data supporting its use in AF patients presenting with ACS are limited. Objective We sought to evaluate the efficacy of dabigatran vs. VKA in the management of AF patients undergoing percutaneous coronary intervention for an ACS. Methods In this open‐label study, 133 consecutive patients received dabigatran plus clopidogrel. Another cohort of 133 patients treated with VKA plus clopidogrel was used as the control group. Results After propensity score adjustment, the cumulative incidence of major adverse cardiovascular events over 24 months was higher with dabigatran vs. VKA (adjusted hazard ratio, 2.28; 95% confidence interval, 1.46–3.56). Similar rates of major bleeding were found (adjusted hazard ratio, 1.17; 95% confidence interval, 0.46–2.96). Conclusions In AF patients presenting with ACS, replacement of VKA by dabigatran concurrently with clopidogrel is associated with an increased thrombotic risk, without a reduction in major bleeding.