Outcomes of Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention Receiving an Oral Anticoagulant and Dual Antiplatelet Therapy
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Objectives The purpose of this study was to determine whether bleeding risk varies depending on which P2Y12 receptor inhibitor agent is used.Background Prior studies have shown significant bleeding risk among patients treated with triple therapy (i.e., oral anticoagulant, P2Y12 receptor inhibitor, and aspirin).Methods We evaluated patients with acute myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) at 233 hospitals in the United States enrolled in the TRANSLATE-ACS (Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study (April 2010 to October 2012). Using inverse probability-weighted propensity modeling, we compared 6-month adjusted risks of Bleeding Academic Research Consortium (BARC) bleeding, stratifying by whether or not bleeding was associated with rehospitalization among patients discharged on aspirin + anticoagulant + clopidogrel (triple-C), aspirin + anticoagulant + prasugrel (triple-P), aspirin + clopidogrel (dual-C), or aspirin + prasugrel (dual-P).Results Of 11,756 MI patients, 526 (4.5%) were discharged on triple-C, 91 (0.8%) on triple-P, 7,715 (66%) on dual-C, and 3,424 (29%) on dual-P. Compared with dual-therapy patients, triple-therapy patients had significantly higher any BARC-defined bleeding. Triple-P was associated with a greater risk of any BARC-defined bleeding events compared with triple-C. This finding was driven mostly by an increased risk of bleeding events that were patient-reported only and did not require rehospitalization. There were no significant differences in bleeding requiring rehospitalization between the triple-P and -C groups.Conclusions Among MI patients, the addition of an oral anticoagulant was associated with a significantly greater risk of any BARC-defined bleeding relative to dual antiplatelet therapy, regardless of which P2Y12 receptor inhibitor was selected. Among patients on triple therapy, prasugrel use was associated with higher patient-reported-only bleeding, but not bleeding requiring rehospitalization, than clopidogrel-treated patients.
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The use of prasugrel or ticagrelor as part of triple therapy is associated with a greater risk of major bleeding compared with clopidogrel.
“The use of prasugrel or ticagrelor as part of triple therapy should be avoided unless there is a clear need for these agents (e.g.stent thrombosis on aspirin plus clopidogrel), given the lack of evidence and the greater risk of major bleeding compared with clopidogrel.522,523”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [523]
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- Authors
- Jackson, L. R., Ju, C., Zettler, M., Messenger, J. C., Cohen, D. J., Stone, G. W., Baker, B. A., Effron, M., Peterson, E. D., & Wang, T. Y.
- Affiliations
- Duke University (US)
- Eli Lilly (United States) (US)
- University of Colorado Anschutz (US)
- Saint Luke's Hospital (US)
- Columbia University (US)
- Daiichi Sankyo (United States) (US)
- Corresponding author
- Jackson, Larry R.
- ORCID
- Venue
- JACC: Cardiovascular Interventions
- Publisher
- Elsevier BV
- Published
- 2015-12
- Volume
- 8
- Issue
- 14
- Pages
- 1880-1889
- ISSN
- 1876-7605 (ISSN-L)
- 1936-8798
- OpenAlex
- W2198571942
- Cited by
- 97
- References
- 23
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 3 · 2023: 4 · 2022: 8 · 2021: 10 · 2020: 10 · 2019: 11 · 2018: 16 · 2017: 11 · 2016: 19 · 2015: 1
- FWCI
- 11.39
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- JACC: Cardiovascular Interventions (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
- Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
- Keywords
- acute myocardial infarction, percutaneous coronary intervention, oral anticoagulants, dual antiplatelet therapy, triple therapy, P2Y12 inhibitors, prasugrel, clopidogrel, bleeding risk, hospital readmission
- MeSH terms
- Prasugrel Hydrochloride, Clopidogrel, Administration, Oral, Aged, Aspirin, Dose-Response Relationship, Drug, Drug Therapy, Combination, Female, Follow-Up Studies, Hemorrhage, Humans, Male, Middle Aged, Myocardial Infarction, Platelet Aggregation Inhibitors, Retrospective Studies, Risk Factors, Ticlopidine, Time Factors, United States, Incidence, Survival Rate, Treatment Outcome, Risk Assessment, Purinergic P2Y Receptor Antagonists, Percutaneous Coronary Intervention
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