Abstract
Direct oral anticoagulants (DOACs) are standard of care for venous thromboembolism (VTE) treatment and stroke prevention in atrial fibrillation (AF). Adding antiplatelet therapy (APT) to an oral anticoagulant (OAC) causes a 2-fold increase in major bleeding. As such, recent guidelines recommend limiting the duration and indication of combined therapy in patients already on an OAC. Despite these recommendations, approximately one-third of anticoagulated patients are prescribed concomitant APT. University of Utah Health patients receiving DOAC + APT between August 1, 2019 and November 30, 2019 were included. These were categorized into four groups by APT indication: primary atherosclerotic cardiovascular disease (ASCVD) prevention, ASCVD-no percutaneous coronary intervention (PCI), ASCVD-PCI ≤ 12 months prior, ASCVD-PCI > 12 months prior. The primary outcome was the proportion of DOAC patients receiving concomitant APT for each indication. During the study period, 347 patients received DOAC + APT, primarily for AF (59.1%) or VTE (33.1%), and the most common DOAC was apixaban (76.7%).The most common indication for APT was ASCVD-no PCI (47.3%), followed by ASCVD-PCI > 12 months prior (30.8%), primary ASCVD prevention (18.7%), and ASCVD-PCI ≤ 12 months prior (1.7%). Five patients (1.4%) were on APT with unclear indication. Based on recent guidelines limiting indications and duration of APT added to anticoagulation, over 95% of patients in this single-center study warranted re-assessment of APT indication, with stable ASCVD and primary prevention being prime targets for APT de-prescribing. This study highlights the tremendous potential to improve patient safety and reduce bleeding harm.
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All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by AA and JS. The first draft of the manuscript was written by AA and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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Anisa Amirtabar and John Saunders declares that they have no conflicts of interest. Sara R. Vazquez declares that she is an Editorial Consult for UpToDate® and a Member of the Anticoagulation Forum Board of Directors. Daniel M. Witt declares that he is a Member of the Anticoagulation Forum Advisory Council and has received grant funding unrelated to this study from Roche Diagnostics Corporation (RD003737) and the Agency for Healthcare Research and Quality (1 R18 HS027960-01).
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This study was approved by the University of Utah Health Institutional Review Board.
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Amirtabar, A., Vazquez, S.R., Saunders, J. et al. Antiplatelet therapy indication in patients also prescribed direct oral anticoagulants. J Thromb Thrombolysis 55, 185–188 (2023). https://doi.org/10.1007/s11239-021-02602-4
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DOI: https://doi.org/10.1007/s11239-021-02602-4