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Prophylactic warfarin therapy after primary percutaneous coronary intervention for anterior ST-segment elevation
Michel R Le May1, Sudikshya Acharya1, George A Wells1
1University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Insights
Adding warfarin to dual-antiplatelet therapy in STEMI patients with apical dysfunction did not improve outcomes. This triple therapy increased the risk of adverse events, including death, stroke, and major bleeding, without providing clinical benefit.
Area of Science:
- Cardiology
- Internal Medicine
Background:
- Current guidelines recommend oral anticoagulation with dual-antiplatelet therapy for ST-segment elevation myocardial infarction (STEMI) patients exhibiting left ventricular apical akinesis or dyskinesis to prevent thromboembolic events.
- However, the clinical benefits and risks of this triple therapy strategy remain largely unelucidated.
Purpose of the Study:
- To investigate the efficacy and safety of adding oral anticoagulation (warfarin) to dual-antiplatelet therapy in patients with anterior wall STEMI and apical akinesis or dyskinesis following primary percutaneous coronary intervention (PCI).
Main Methods:
- A retrospective study identified 460 anterior STEMI patients with apical akinesis/dyskinesis post-PCI between 2004 and 2010.
- Patients were divided into two groups: those prescribed warfarin (n=131) and those not (n=329).
- The primary outcome was a composite of net adverse clinical events (NACE) at 180 days, including all-cause mortality, stroke, reinfarction, and major bleeding.
Main Results:
- Patients receiving warfarin had significantly higher rates of NACE (14.7% vs. 4.6%, P=0.001), death (5.4% vs. 1.5%, P=0.04), stroke (3.1% vs. 0.3%, P=0.02), and major bleeding (8.5% vs. 1.8%, P<0.0001) compared to those without warfarin.
- Propensity score and multivariable analyses confirmed that warfarin therapy was an independent predictor of increased NACE.
Conclusions:
- The addition of warfarin therapy to dual-antiplatelet therapy in patients with anterior STEMI and apical akinesis or dyskinesis after primary PCI is not supported by these findings.
- This approach was associated with a higher risk of adverse clinical events without demonstrated benefit.
Objectives:
This study sought to determine the benefits of adding oral anticoagulation therapy in patients with anterior wall ST-segment elevation myocardial infarction (STEMI) patients after primary percutaneous coronary intervention (PCI).
Background:
Guidelines suggest adding oral anticoagulation to dual-antiplatelet therapy in patients with STEMI when left ventricular apical akinesis or dyskinesis is present to prevent thromboembolic complications. The benefits of this triple therapy remain unknown.
Methods:
We identified patients with anterior STEMI referred (PCI) between July 2004 and June 2010 with apical akinesis or dyskinesis on transthoracic echocardiography. We compared patients who were prescribed warfarin to patients who were not. We excluded patients with left ventricular thrombus, a separate need for oral anticoagulation, and previous intracranial bleeding. The primary outcome was a composite of net adverse clinical events (NACE) consisting of all-cause mortality, stroke, reinfarction, and major bleeding at 180 days.
Results:
Among 460 patients who qualified, 131 were discharged on warfarin therapy and 329 without warfarin therapy. Dual-antiplatelet therapy was prescribed for 99.2% of the patients in the warfarin group and for 97.6% of the patients in the no warfarin group (p = 0.46). Compared with patients in the no warfarin group, patients in the warfarin group had higher rates of NACE (14.7% vs. 4.6%, p = 0.001), death (5.4% vs. 1.5%, p = 0.04), stroke (3.1% vs. 0.3%, p = 0.02), and major bleeding (8.5% vs. 1.8%, p < 0.0001). By propensity score analysis, allocation to warfarin therapy was an independent predictor of NACE (odds ratio [OR]: 4.01, 95% confidence interval: 2.15 to 7.50, p < 0.0001). In a separate multivariable analysis, the OR of NACE remained significantly higher compared with patients who were not prescribed warfarin (OR: 3.13, 95% confidence interval: 1.34 to 7.22, p = 0.007).
Conclusions:
Our results do not support the addition of warfarin therapy after primary PCI in patients with apical akinesis or dyskinesis.
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