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Published on: February 28, 2012
Anticoagulant and Antiplatelet Prescribing Patterns for Patients with Atrial Fibrillation after Percutaneous Coronary
Erin A Woods1, Margaret L Ackman2, Michelle M Graham3
1, BSP, ACPR, is with Pharmacy Services, University of Alberta Hospital/Mazankowski Alberta Heart Institute, Alberta Health Services, Edmonton, Alberta.
Insights
Triple antithrombotic therapy (TAT) use was low in nonvalvular atrial fibrillation patients post-PCI. Many received non-evidence-based treatments, highlighting a gap between guidelines and practice for anticoagulant and antiplatelet therapy.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Practice
Background:
- Current guidelines recommend triple antithrombotic therapy (TAT) for nonvalvular atrial fibrillation (NVAF) patients post-percutaneous coronary intervention (PCI).
- Prescribing patterns for anticoagulant and antiplatelet therapy in this complex population are not well-documented.
- The optimal choice of therapy remains ambiguous.
Purpose of the Study:
- To characterize local prescribing patterns of anticoagulant/antiplatelet therapy.
- To evaluate adherence to guidelines in NVAF patients undergoing PCI.
Main Methods:
- Retrospective chart review at a single quaternary cardiology center.
- Inclusion criteria: NVAF patients with CHADS2 score ≥1 undergoing PCI (2011-2013).
- Exclusion criteria: Cardiovascular surgery, transcatheter aortic valve replacement, mechanical devices, TAT component allergy.
Main Results:
- Seventy NVAF patients were analyzed; median age 75 years, 74% male.
- Only 43% received TAT at discharge; 39% received dual antiplatelet therapy (DAPT).
- 9% received direct-acting oral anticoagulants with 2 antiplatelet agents; 54% received ASA, oral anticoagulant, and P2Y12 inhibitor.
Conclusions:
- Less than half of NVAF patients post-PCI received guideline-recommended TAT.
- Nearly 20% received non-evidence-based therapy, indicating suboptimal treatment strategies.
- Observed TAT utilization rates were lower than previously reported in literature.
Background:
Current guidelines recommend triple antithrombotic therapy (TAT), defined as acetylsalicylic acid (ASA), clopidogrel, and warfarin, for patients with nonvalvular atrial fibrillation who have undergone percutaneous coronary intervention with stent implantation. The choice of anticoagulant/antiplatelet therapy in this population is ambiguous and complex, and prescribing patterns are not well documented.
Objective:
To characterize local prescribing patterns for anticoagulant/antiplatelet therapy after percutaneous coronary intervention in patients with nonvalvular atrial fibrillation.
Methods:
A chart review was conducted at a single quaternary cardiology centre. Patients with nonvalvular atrial fibrillation were identified via medical records, and those who underwent percutaneous coronary intervention were identified using a local clinical patient registry. Adult inpatients with nonvalvular atrial fibrillation and a CHADS2 score (based on congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke) of 1 or higher who underwent percutaneous coronary intervention from 2011 to 2013 were included. Patients undergoing cardiovascular surgery or transcatheter aortic valve replacement, those with mechanical devices requiring anticoagulation, and those with an allergy to any component of TAT were excluded.
Results:
Seventy patients were included. The median age was 75 years, and 52 (74%) were men. At discharge, 30 (43%) were receiving TAT and 27 (39%) were receiving dual antiplatelet therapy (clopidogrel and ASA). No patients received the combination of warfarin and clopidogrel. Among those who received TAT, 90% (19 of 21) who received a bare metal stent had a recommended duration of 1 month, and 75% (6 of 8) who received a drug-eluting stent had a recommended duration of 1 year. Direct-acting oral anticoagulants with 2 antiplatelet drugs were prescribed for 9% (6 of 70) of the patients, and 10% (7 of 70) received ticagrelor and ASA with or without warfarin. Overall, the combination of ASA, oral anticoagulant, and P2Y12 inhibitor was used for 54% (38/70) of the patients.
Conclusions:
Fewer than half of the patients in this study received TAT, and almost 20% received non-evidence-based therapy with a direct-acting oral anticoagulant or ticagrelor, alone or in combination. Despite current guideline recommendations, the rate of TAT utilization was lower than rates reported in the literature.
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