Use and Outcomes of Triple Therapy Among Older Patients With Acute Myocardial Infarction and Atrial Fibrillation

doi:10.1016/j.jacc.2015.05.062

Journal of the American College of Cardiology

Volume 66, Issue 6, 11 August 2015, Pages 616-627

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Abstract

Background

Antithrombotic therapy for acute myocardial infarction (MI) with atrial fibrillation (AF) among higher risk older patients treated with percutaneous coronary intervention (PCI) remains unclear.

Objectives

This study sought to determine appropriate antithrombotic therapy for acute MI patients with AF treated with PCI.

Methods

We examined 4,959 patients ≥65 years of age with acute MI and AF who underwent coronary stenting (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines). The primary effectiveness outcome was 2-year major adverse cardiac events (MACE) comprising death, readmission for MI, or stroke; the primary safety outcome was bleeding readmission. Outcomes with dual antiplatelet therapy (DAPT) or triple therapy (DAPT plus warfarin) were compared using Cox proportional hazard modeling with inverse probability-weighted propensity adjustment.

Results

Among 4,959 patients, 27.6% (n = 1,370) were discharged on triple therapy. Relative to DAPT, patients on triple therapy had a similar risk of MACE (adjusted hazard ratio [HR]: 0.99 [95% confidence interval (CI): 0.86 to 1.16]) but significantly greater risk of bleeding requiring hospitalization (adjusted HR: 1.61 [95% CI: 1.31 to 1.97]) and greater risk of intracranial hemorrhage (adjusted HR: 2.04 [95% CI: 1.25 to 3.34]). Of 1,591 Medicare Part D patients, 90-day post-discharge warfarin persistence among patients discharged on warfarin was 93.2% (n = 412). Results of 90-day landmark analyses comparing triple therapy versus DAPT in patients persistently on warfarin versus those not discharged on warfarin who had not filled a warfarin prescription were similar to our primary findings.

Conclusions

Approximately 1 in 4 older AF patients undergoing PCI for MI were discharged on triple therapy. Those receiving triple therapy versus DAPT had higher rates of major bleeding without a measurable difference in composite MI, death, or stroke.

Key Words

antithrombotic therapy

atrial fibrillation

myocardial infarction

percutaneous coronary intervention

Abbreviations and Acronyms

atrial fibrillation

CABG

coronary artery bypass grafting

CHADS₂

congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke/transient ischemic attack

confidence interval

DAPT

dual antiplatelet therapy

DES

drug-eluting stent(s)

hazard ratio

MACE

major adverse cardiac event(s)

myocardial infarction

NSTEMI

non–ST-segment elevation myocardial infarction

PCI

percutaneous coronary intervention

STEMI

ST-segment elevation myocardial infarction

Cited by (0)

: This work was supported by grant number U19HS021092 from the Agency for Healthcare Research and Quality. The ACTION Registry–GWTG is an initiative of the American College of Cardiology Foundation and the American Heart Association, with partnering support from the Society of Chest Pain Centers, the American College of Emergency Physicians, and the Society of Hospital Medicine. This research was supported by the American College of Cardiology Foundation's National Cardiovascular Data Registry. The views expressed in this paper represent those of the authors and do not necessarily represent the official views of the National Cardiovascular Data Registry or its associated professional societies identified at www.ncdr.com. Dr. Hess has received research grant support from Gilead Sciences, Inc. Dr. Peterson has received institutional grant support from the American College of Cardiology, the American Heart Association, Eli Lilly, and Janssen; and consulting fees (including Continuing Medical Education) from Merck & Co., Boehringer Ingelheim, Genentech, Janssen, and Sanofi. Dr. Bhatt has served on the advisory board for Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; is on the board of directors for Boston VA Research Institute and Society of Cardiovascular Patient Care; is chair for the American Heart Association Get With The Guidelines Steering Committee; is on the data monitoring committees for, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, and Population Health Research Institute has received honoraria from the American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), WebMD (Continuing Medical Education steering committees), Clinical Cardiology (Deputy Editor); has received research funding from Amarin, AstraZeneca, Biotronik, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi, St. Jude Medical, and The Medicines Company; has served as a trustee for the American College of Cardiology; and has performed unfunded research for FlowCo, PLx Pharma, and Takeda. Dr. Saucedo is a member of the advisory board of Janssen Pharmaceuticals and Eli Lilly. Dr. Wang has received institutional research grant support from AstraZeneca, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, Gilead Sciences, GlaxoSmithKline, and Regeneron; and honoraria from AstraZeneca, Eli Lilly, and PREMIER Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Jonathan Tobis, MD, served as Guest Editor for this paper.

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