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Bleeding After Initiation of Multiple Antithrombotic Drugs, Including Triple Therapy, in Atrial Fibrillation Patients Following Myocardial Infarction and Coronary Intervention: A Nationwide Cohort Study
Abstract
Background—: Uncertainty remains over optimal antithrombotic treatment of patients with atrial fibrillation presenting with myocardial infarction and/or undergoing percutaneous coronary intervention. We investigated the risk and time frame for bleeding following myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation according to antithrombotic treatment. Methods and Results—: Patients with atrial fibrillation and admitted with myocardial infarction or for percutaneous coronary intervention between 2000 and 2009 (11 480 subjects, mean age 75.6 years [SD ±10.3], males 60.9%) were identified by individual level linkage of nationwide registries in Denmark. Fatal or nonfatal (requiring hospitalization) bleeding was determined according to antithrombotic treatment regimen: triple therapy (TT) with vitamin K antagonist (VKA)+aspirin+clopidogrel, VKA+antiplatelet, and dual antiplatelet therapy with aspirin+clopidogrel. We calculated crude incidence rates and adjusted hazard ratios by Cox regression models. Within 1 year, 728 bleeding events were recorded (6.3%); 79 were fatal (0.7%). Within 30 days, rates were 22.6, 20.3, and 14.3 bleeding events per 100 person-years for TT, VKA+antiplatelet, and dual antiplatelet therapy, respectively. Both early (within 90 days) and delayed (90–360 days) bleeding risk with TT exposure in relation to VKA+antiplatelet was increased; hazard ratio 1.47 (1.04;2.08) and 1.36 (0.95;1.95), respectively. No significant difference in thromboembolic risk was observed for TT versus VKA+antiplatelet; hazard ratio, 1.15 (0.95;1.40). Conclusions—: High risk of bleeding is immediately evident with TT after myocardial infarction/percutaneous coronary intervention in patients with atrial fibrillation. A continually elevated risk associated with TT indicates no safe therapeutic window, and TT should only be prescribed after thorough bleeding risk assessment of patients.
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“Approximately 15% of AF patients in contemporary trials 513 and registries [514][515][516] have a history of myocardial 1498 infarction.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [515]
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“of total bleeding ( fatal events ) / person years at risk Triple therapy VKA + antiplatelet therapy Dual antiplatelet therap y VKA monotherapy Single antiplatelet therapy 27 ( 1) / 119 30 ( 2) / 148 37 ( 1) / 259 5 ( 1) / 59 48 ( 11) / 309 39 ( 0) / 193 38 ( 3) / 291 40 ( 2) / 596 9 ( 0) / 104 54 (12) / 561 21 ( 3) /…”
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Lugo‐Gavidia, L. M., & Ferreiro, J. L. (2019) · Revista Española de Cardiología Suplementos · doi:10.1016/s1131-3587(19)30032-9
Conclusiones y recomendaciones prácticas
Cequier, A. R. (2019) · Revista Española de Cardiología Suplementos · doi:10.1016/s1131-3587(19)30033-0
Intrazerebrale Blutung unter oraler Antikoagulation wegen Vorhofflimmern
Block, F. (2016) · Springer eBooks · doi:10.1007/978-3-662-47880-6_5
Triple Therapy: Risky but Sometimes Necessary
Sørensen, R., & Gislason, G. (2013) · Springer eBooks · doi:10.1007/978-1-4471-5424-2_6
Self-citation
Metadata
- Authors
- Lamberts, M., Olesen, J. B., Ruwald, M. H., Hansen, C. M., Karasoy, D., Kristensen, S. L., Køber, L., Torp-Pedersen, C., Gislason, G. H., & Hansen, M. L.
- Affiliations
- Copenhagen University Hospital (DK)
- Gentofte Hospital (DK)
- ORCID
- Venue
- Circulation
- Published
- 2012-09-04
- Volume
- 126
- Issue
- 10
- Pages
- 1185-1193
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2108659563
- Cited by
- 413
- References
- 0
- Citations by year
- 2026: 7 · 2025: 6 · 2024: 9 · 2023: 10 · 2022: 16 · 2021: 24 · 2020: 36 · 2019: 42 · 2018: 42 · 2017: 43 · 2016: 37 · 2015: 40 · 2014: 41 · 2013: 53 · 2012: 6
- FWCI
- 28.82
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation (publishedVersion)
- PubMed (publishedVersion)
- Research at the University of Copenhagen (University of Copenhagen) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
- Keywords
- atrial fibrillation, bleeding risk, triple therapy, vitamin K antagonists, clopidogrel, aspirin, antiplatelet therapy, dual antiplatelet therapy, myocardial infarction, percutaneous coronary intervention, thromboembolic risk, bleeding risk assessment
- MeSH terms
- Clopidogrel, Aged, Aged, 80 and over, Aspirin, Atrial Fibrillation, Denmark, Drug Therapy, Combination, Female, Fibrinolytic Agents, Hemorrhage, Humans, Male, Middle Aged, Myocardial Infarction, Platelet Aggregation Inhibitors, Registries, Risk Factors, Ticlopidine, Vitamin K, Cohort Studies, Comorbidity, Angioplasty, Balloon, Coronary, Stroke, Acute Coronary Syndrome
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