Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis

• Published in: The American heart journal 2021-12, Vol.242, p.71-81
• Main Authors: Dawwas, Ghadeer K., Barnes, Geoffrey D., Dietrich, Eric, Cuker, Adam, Leonard, Charles E., Genuardi, Michael V., Lewis, James D.
• Format: Article
• Language: English
• Subjects: Acute Coronary Syndrome - complications; Acute Coronary Syndrome - drug therapy; Acute coronary syndromes; Administration, Oral; Angioplasty; Anticoagulants; Anticoagulants - administration & dosage; Anticoagulants - adverse effects; Antiplatelet therapy; Aspirin; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Bleeding; Cardiac arrhythmia; Cardiovascular diseases; Cardiovascular Diseases - epidemiology; Cerebral infarction; Clinical medicine; Clinical trials; Codes; Confidence intervals; Demographics; Diabetes; Diagnosis; Disease; Drug Therapy, Combination; Education; Fibrillation; Health hazards; Health services utilization; Heart failure; Hemorrhage - chemically induced; Hemorrhage - epidemiology; Hospitals; Humans; Laboratories; Myocardial infarction; Patients; Platelet Aggregation Inhibitors - adverse effects; Prescription drugs; Retrospective Studies; Robustness (mathematics); Statistical analysis; Stroke; Thromboembolism; United States - epidemiology; Warfarin; Warfarin - administration & dosage; Warfarin - adverse effects
• ISSN: 0002-8703; 1097-6744
• DOI: 10.1016/j.ahj.2021.08.014

Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF). To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF. Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019. New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis. Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time. After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72). Residual confounding. In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.