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Antithrombotic therapies in Canadian atrial fibrillation patients with concomitant coronary artery disease: Insights
James K Chow1, Akshay Bagai2, Mary K Tan3
1University of Edinburgh, Edinburgh, UK.
Insights
Canadian patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) show increased use of dual pathway therapy over triple therapy. Direct oral anticoagulants (DOACs) are now the preferred anticoagulation method.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Managing antithrombotic therapy for atrial fibrillation (AF) patients post-percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) is complex.
- Canadian guidelines recommend specific antithrombotic strategies balancing thrombotic and bleeding risks.
Purpose of the Study:
- To evaluate antithrombotic therapy patterns in Canadian AF patients post-PCI or ACS.
- To assess adherence to guideline recommendations regarding dual pathway therapy versus triple therapy.
Main Methods:
- Multi-centre observational study involving retrospective chart audit of 611 non-valvular AF patients.
- Data collected from August 2018 to December 2020 across eight Canadian provinces.
- Analysis of initial and planned 1-year antithrombotic regimens, including direct oral anticoagulants (DOACs) and proton pump inhibitor use.
Main Results:
- Triple antithrombotic therapy (TAT) was initially common (53.8%), but dual pathway therapy use increased significantly over time (32.7%).
- Direct oral anticoagulants (DOACs) comprised 90.3% of all oral anticoagulants (OACs), with apixaban being most frequent (50.5%).
- Planned 1-year therapy shifted towards OAC monotherapy (76.2%) and dual OAC-based therapies.
Conclusions:
- Canadian physicians are increasingly adopting dual pathway therapy over TAT for AF patients post-PCI/ACS, aligning with guidelines.
- DOACs are the dominant form of anticoagulation, indicating a shift towards evidence-based practice.
- These findings suggest effective management of bleeding and thrombotic risks in this patient population.
Background:
Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS.
Methods And Results:
By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy.
Conclusion:
In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS.
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