PracticeUpdate Cardiology Best of 2018

CONFERENCE COVERAGE 24

Oral Anticoagulants + Antiplatelets Linked to Poor Outcome in Atrial Fibrillation Combined oral anticoagulant and antiplatelet therapy was harmful to patients without an indication for antiplatelets. C ombined oral anticoagulant and anti- platelet therapy has been found to be associated with a worse progno- artery disease nor other forms of ather- osclerosis receiving both medications should consult their doctor.”

Associations between treatment type and outcomes were then examined in patients with an indication for antiplatelet therapy (with coronary artery disease or peripheral artery disease) and those without (no cor- onary artery disease or peripheral artery disease). Compared with oral anticoagulation alone, combined treatment was independently associated with increased risks of all-cause death (HR 1.37, 95% CI 1.02–1.85) and stroke (HR 1.65, 95% CI 1.02–2.65) in patients with- out an indication for antiplatelets, but was not harmful to those with an indication. The GARFIELD-AF registry is the largest prospective global registry of patients with atrial fibrillation (including 57,262 in total and 52,000 patients recruited prospec- tively between 2010 and 2016). Patients with newly diagnosed nonvalvular atrial fibrillation and at least one risk factor for stroke were enrolled from over 1000 centers in 35 countries worldwide, includ- ing from the Americas, Europe, Africa, and the Asia-Pacific region. Follow-up data was captured for a minimum of 2 and up to 8 years after diagnosis to create a comprehensive database of treat- ment decisions and outcomes in everyday clinical practice. GARFIELD-AF offers a unique opportunity to obtain a comprehensive and contempo- rary description of the spectrum of patients with atrial fibrillation and their manage- ment worldwide as they evolve over time. The registry is important in bridging the gap between research and clinical prac- tice, serving to increase awareness of the importance of thrombosis and its treatment. Anticoagulants prevent thrombosis by stopping the circulation of clotting pro- teins. Antiplatelets interfere with platelet adhesion. As recommended in the 2016 ESC guide- lines, nearly all patients diagnosed with atrial fibrillation should be started on oral anticoagulation to prevent stroke. Adding an antiplatelet drug increases the risk of bleeding and is not recommended unless required to prevent coronary or peripheral artery thrombosis, for exam- ple, in patients who have received a stent, suffer a myocardial infarction, or harbor

sis than anticoagulation alone in patients with newly diagnosed atrial fibrillation with- out a clear indication for antiplatelets. This finding of an analysis of the Global Anticoagulant Registry in the FIELD–Atrial Fibrillation (GARFIELD-AF) was reported at ESC 2018. In an ESC press release, Keith Fox, MD, of the University of Edinburgh, UK, said, “These findings challenge the use of com- bined oral anticoagulant and antiplatelet therapy in patients with atrial fibrillation, especially those without an indication for antiplatelet therapy.” He continued, “More than half of patients prescribed both drugs did not have cor- onary artery disease or peripheral artery disease, suggesting that they did not have a clear indication for antiplatelet therapy. “Combined oral anticoagulant and anti- platelet therapy was harmful in patients without an indication for antiplatelets,” Dr. Fox asserted. “In those with an indi- cation, it was not harmful but there did not appear to be any benefit. The results question the use of combined treatment in any patient with atrial fibrillation, but par- ticularly in those without an indication for antiplatelets.” He noted that the findings apply only to full- dose anticoagulation. He added, “Patients with atrial fibrillation yet neither coronary

Dr. Fox and colleagues set out to deter- mine whether adding an antiplatelet to oral anticoagulation therapy in those without a clear indication for an antiplatelet would provide overall benefit or harm. Patients were excluded if they had been prescribed antiplatelets, which included aspirin and P2Y12 receptor inhibitors. The study enrolled 25,815 patients with newly diagnosed atrial fibrillation from 1317 sites in 35 countries. Of those, 3133 patients were prescribed antiplatelet and oral anticoagulant therapy for the first time and 22,682 were prescribed oral anticoag- ulants alone. Patients receiving oral anticoagulants and antiplatelets exhibited a higher prevalence of coronary artery disease, acute coronary syndrome, and stroke. A total of 1743 (56%) patients prescribed both drugs, however, harbored neither coronary artery disease nor peripheral artery disease. Patients were followed for a minimum of 12 months. Compared with oral anticoagulation alone, combined treatment with oral anti- coagulation and antiplatelet therapy was independently associated with increased risks of major bleeding (HR 1.45, 95% CI 0.94–2.23), all-cause death (HR 1.31, 95% CI 1.05–1.62), and stroke (HR 1.60, 95% CI 1.08–2.35).

peripheral artery disease. www.practiceupdate.com/c/72716

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