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Triple therapy after PCI - Warfarin treatment quality and bleeding risk
Daniel Wadell1, Jens Jensen2, Erling Englund3
1Department of Public Health and Clinical Medicine, Umeå University, Sundsvall, Sweden.
Insights
Poor warfarin treatment quality, measured by individual time within therapeutic INR range (iTTR), significantly increases bleeding risk in patients undergoing triple therapy after percutaneous coronary intervention (PCI). Maintaining a higher iTTR is crucial for reducing bleeding complications.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Triple therapy with warfarin, aspirin, and clopidogrel is used post-percutaneous coronary intervention (PCI).
- This combination therapy increases the risk of bleeding complications.
- The impact of warfarin treatment quality on bleeding risk in this context is not fully understood.
Purpose of the Study:
- To investigate the association between warfarin treatment quality, assessed by individual time within therapeutic INR range (iTTR), and bleeding complications.
- To identify predictors of bleeding in patients receiving triple therapy after PCI.
Main Methods:
- Retrospective study of 601 patients undergoing triple therapy post-PCI.
- Data sourced from Swedish registries including SCAAR, Swedish Patient Registry, Prescribed Drug Registry, and Auricula.
- Patients categorized into iTTR groups (<50%, 50-69.9%, 70-84.9%, >85%) to analyze bleeding event rates.
Main Results:
- A total of 39 patients (6.5%) experienced bleeding complications (BARC type 2).
- Bleeding was significantly more frequent in patients with iTTR < 70% (9.3%) compared to iTTR > 70% (3.7%).
- Bleeding risk increased progressively with lower iTTR, with rates of 8.0 and 44.9 per 100 treatment years for iTTR > 85% and iTTR < 50%, respectively. Low BMI, anemia history, and iTTR < 70% were independent predictors of bleeding.
Conclusions:
- Triple therapy post-PCI is associated with a high bleeding risk.
- Warfarin treatment quality (iTTR) and a history of anemia are significant independent predictors of bleeding.
- Close monitoring of iTTR in patients on triple therapy after PCI is recommended to mitigate bleeding risks.
Background:
A combination of warfarin, aspirin and clopidogrel is indicated after percutaneous coronary intervention (PCI) in some patients, despite the higher risk of bleeding inferred by this triple therapy.
Objectives:
Whether the treatment quality of warfarin measured by iTTR (individual time within therapeutic INR range) is associated with bleeding complications during triple therapy after PCI.
Methods:
A retrospective register study consisting of 601 triple treated PCI patients from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). The cohort was cross-matched with the Swedish Patient Registry for background characteristics and bleeding complications up to 6 months after PCI using ICD10 codes, the Prescribed Drug Registry for ongoing medications, and the national oral anticoagulation registry Auricula for warfarin treatment quality. The patients were grouped into four iTTR groups: <50%, 50-69.9%, 70-84.9% and >85% as well as iTTR above or below 70%.
Results:
Of 601 patients, 39 (6.5%) had a bleeding complication (type 2 according to BARC). Bleeding was more common for iTTR<70% compared to iTTR>70%, 28 (9.3%) vs. 11 (3.7%) (p = 0.005). The bleeding frequency increased gradually from the best group, iTTR>85% with four bleeders (3.3%) up to 17 bleeders (13.3%) in the worst group with iTTR<50% (p = 0.003), with a corresponding bleeding rate per 100 treatment years of 8.0 and 44.9, respectively. In multivariate analysis low BMI, HR 1.11 (95% CI 1.01-1.22), a medical history of anemia HR 3.17 (1.16-8.69) and iTTR < 70% HR 2.86 (1.25-6.53) increased the risk of bleeding.
Conclusion:
Triple therapy after PCI confers a high risk of bleeding events. Warfarin treatment quality measured by iTTR as well as a medical history of anemia are strong independent predictors of bleeding in these patients. Physicians should pay more attention to iTTR after PCI.
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