Abstract
This study aimed to compare major hemorrhage rates among patients receiving warfarin, acetylsalicylic acid (ASA), and clopidogrel to those receiving ASA and clopidogrel following percutaneous coronary intervention with stent implantation. This retrospective cohort study identified patients with stents implanted between September 1, 2003 and December 31, 2006. Patients treated with warfarin, ASA, and clopidogrel within 30 days of hospital discharge (Triple Therapy group) were matched by age, sex, and stent type to patients treated with ASA and clopidogrel (Dual Therapy group). Outcomes included the incidence rates of major hemorrhage and major adverse coronary events (MACE) within 12 months of stent implantation. There were 175 and 339 patients in the Triple Therapy and Dual Therapy groups, respectively. There were 25 (14.3%) and 10 (3.0%) major hemorrhages in the Triple Therapy and Dual Therapy groups, respectively (OR 9.0; 95% CI, 3.1–26.1). Patients in the Triple Therapy group had a greater likelihood of MACE compared to patients in the Dual Therapy group (OR 2.0; 95% CI 1.1–3.8). Post-stent treatment with warfarin, ASA, and clopidogrel was associated with a substantially greater likelihood of major hemorrhage than treatment with ASA and clopidogrel alone.
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Rosamond W, Flegal K, Furie K et al (2008) Heart disease and stroke statistics—2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 117:e25–e146. doi:10.1161/CIRCULATIONAHA.107.187998
Antman EM, Hand M, Armstrong PW et al (2008) 2007 Focused Update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 writing group to review new evidence and update the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction, writing on behalf of the 2004 writing committee. Circulation 117:296–329. doi:10.1161/CIRCULATIONAHA.107.188209
King SB III, Smith SC Jr, Hirshfeld JW Jr et al (2008) 2007 Focused Update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: 2007 writing group to review new evidence and update the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention, writing on behalf of the 2005 writing committee. Circulation 117:261–295. doi:10.1161/CIRCULATIONAHA.107.188208
Anderson JL, Adams CD, Antman EM et al (2007) ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 guidelines for the management of patients with unstable Angina/Non ST-elevation myocardial infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 116:e148–e304. doi:10.1161/CIRCULATIONAHA.107.737312
Mehta SR, Yusuf S, Peters RJ et al (2001) Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 358:527–533. doi:10.1016/S0140-6736(01)05701-4
Steinhubl SR, Berger PB, Mann JT III et al (2002) Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 288:2411–2420. doi:10.1001/jama.288.19.2411
Hirsh J, Guyatt G, Albers GW et al (2008) Executive summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133:71S–109S. doi:10.1378/chest.08-0693
Rossini R, Musumeci G, Lettieri C et al (2008) Long-term outcomes in patients undergoing coronary stenting on dual oral antiplatelet treatment requiring oral anticoagulant therapy. Am J Cardiol 102:1618–1623. doi:10.1016/j.amjcard.2008.08.021
Sandhoff BG, Nies LK, Olson KL et al (2007) Clinical pharmacy cardiac risk service for managing patients with coronary artery disease in a health maintenance organization. Am J Health Syst Pharm 64:77–84. doi:10.2146/ajhp060022
Witt DM, Sadler MA, Shanahan RL et al (2005) Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest 127:1515–1522. doi:10.1378/chest.127.5.1515
DeEugenio D, Kolman L, DeCaro M et al (2007) Risk of major bleeding with concomitant dual antiplatelet therapy after percutaneous coronary intervention in patients receiving long-term warfarin therapy. Pharmacotherapy 27:691–696. doi:10.1592/phco.27.5.691
Orford JL, Fasseas P, Melby S et al (2004) Safety and efficacy of aspirin, clopidogrel, and warfarin after coronary stent placement in patients with an indication for anticoagulation. Am Heart J 147:463–467. doi:10.1016/j.ahj.2003.06.004
Mattichak SJ, Reed PS, Gallagher MJ et al (2005) Evaluation of safety of warfarin in combination with antiplatelet therapy for patients treated with coronary stents for acute myocardial infarction. J Interv Cardiol 18:163–166. doi:10.1111/j.1540-8183.2005.04065.x
Khurram Z, Chou E, Minutello R et al (2006) Combination therapy with aspirin, clopidogrel and warfarin following coronary stenting is associated with a significant risk of bleeding. J Invasive Cardiol 18:162–164
Porter A, Konstantino Y, Iakobishvili Z et al (2006) Short-term triple therapy with aspirin, warfarin, and a thienopyridine among patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 68:56–61. doi:10.1002/ccd.20733
Karjalainen PP, Porela P, Ylitalo A et al (2007) Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J 28:726–732. doi:10.1093/eurheartj/ehl488
Sarafoff N, Ndrepepa G, Mehilli J et al (2008) Aspirin and clopidogrel with or without phenprocoumon after drug eluting coronary stent placement in patients on chronic oral anticoagulation. J Intern Med 264:472–480. doi:10.1111/j.1365-2796.2008.01989.x
Ruiz-Nodar JM, Marin F, Hurtado JA et al (2008) Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis. J Am Coll Cardiol 51:818–825. doi:10.1016/j.jacc.2007.11.035
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Olson, K.L., Delate, T., Johnson, S.G. et al. Incidence of hemorrhage among anticoagulated patients receiving antiplatelet therapy after percutaneous coronary intervention. J Thromb Thrombolysis 29, 316–321 (2010). https://doi.org/10.1007/s11239-009-0343-1
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DOI: https://doi.org/10.1007/s11239-009-0343-1