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Published on: February 28, 2012
Adverse cardiovascular events in acute coronary syndrome with indications for anticoagulation
Stacey Knight1, Raymond O McCubrey2, Zhong Yuan3
1Intermountain Medical Center, Intermountain Heart Institute, 5121 S., Cottonwood St, Murray, UT 84107, USAUniversity of Utah School of Medicine, Salt Lake City, UT, USA Stacey.knight@imail.org.
Insights
Antithrombotic strategy did not significantly impact major adverse cardiovascular events in acute coronary syndrome patients needing anticoagulation. Further randomized trials are needed for evidence-based management in this complex population.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Randomized trials for acute coronary syndrome (ACS) often exclude patients requiring anticoagulation (AC) due to comorbidities like atrial fibrillation (AF) or venous thromboembolism (VTE).
- This exclusion limits evidence-based treatment strategies for ACS patients with concurrent indications for AC.
Purpose of the Study:
- To evaluate the 2-year clinical outcomes of ACS patients who require AC.
- To determine if different antithrombotic (AT) strategies influence major adverse cardiovascular events (MACE) in this population.
Main Methods:
- A cohort of 619 ACS patients with AC indications (VTE, or AF with CHADS2 score ≥2) from 2004-2009 was analyzed.
- Cox proportional hazards models assessed the association between at-discharge AT strategy (single antiplatelet ± AC, dual antiplatelet (DAP) ± AC, or AC only) and MACE (all-cause death, MI, stroke).
Main Results:
- 42.2% of patients experienced a MACE event over 2 years.
- The at-discharge AT strategy was not a significant predictor of MACE (p > 0.09).
- Factors associated with MACE included high mortality risk score, prior myocardial infarction (MI), and ST-elevation MI or non-ST-elevation MI presentation.
Conclusions:
- In this real-world observational study, AT strategy at discharge was not significantly linked to 2-year MACE risk in ACS patients needing AC.
- These findings highlight the need for randomized controlled trials to establish optimal management for this high-risk patient group.
Objectives:
Randomized acute coronary syndrome (ACS) trials testing various antithrombotic (AT) regimens have largely excluded patients with coexisting conditions and indications for anticoagulation (AC). The purpose of this study is to examine the 2-year clinical outcomes of patients with ACS with indication for AC due to venous thromboembolism (VTE) during hospitalization for the ACS event or a prior or new diagnosis of atrial fibrillation (AF) with a CHADS2 (Congestive heart failure; Hypertension; Age; Diabetes; previous ischemic Stroke) score ⩾2.
Methods:
ACS patients with AC indication from 2004 to 2009 were identified (n = 619). A Cox proportional hazards model was used to examine the primary efficacy outcome of major adverse cardiovascular events (MACE) including all-cause death, myocardial infarction (MI) or stroke. The primary explanatory variable was at-discharge antithrombotic strategy [single antiplatelet ± AC, dual antiplatelet (DAP) ± AC or AC only; referent DAP + AC].
Results:
A total of 261 (42.2%) patients had a MACE event. AT strategy was not a significant factor for MACE (all p > 0.09). The factors associated with MACE were high mortality risk score [hazard ratio (HR)=1.87, 95% confidence interval (CI): 1.39- 2.52; p < 0.001), prior MI (HR = 1.44, 95% CI: 1.03-2.01; p= 0.033) and presentation of ST elevation MI (HR = 2.70, 95% CI: 1.61-4.51; p < 0.001) or non-ST elevation MI (HR = 1.70, 95% CI: 1.15-2.49; p < 0.001) compared with angina.
Conclusions:
In this real world observational study, the at-discharge AT strategy was not significantly associated with the 2-year risk of MACE. These findings do not negate the need for randomized trials to generate evidence-based approaches to management of this important population.
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