Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction

被引:43
作者
Fosbol, Emil L. [1 ]
Wang, Tracy Y. [1 ]
Li, Shuang [1 ]
Piccini, Jonathan P. [1 ]
Lopes, Renato D. [1 ]
Shah, Bimal [1 ]
Mills, Roger M. [2 ]
Klaskala, Winslow [2 ]
Alexander, Karen P. [1 ]
Thomas, Laine [1 ]
Roe, Matthew T. [1 ]
Peterson, Eric D. [1 ]
机构
[1] Duke Univ, Med Ctr, Duke Clin Res Inst, Durham, NC 27705 USA
[2] Sci Affairs LLC, Janssen Pharmaceut, Titusville, NJ USA
关键词
HEART RHYTHM ASSOCIATION; ORAL ANTICOAGULATION; WARFARIN ANTICOAGULATION; PRACTICE GUIDELINES; CONSENSUS DOCUMENT; AMERICAN-COLLEGE; EUROPEAN-SOCIETY; UNSTABLE ANGINA; TASK-FORCE; THERAPY;
D O I
10.1016/j.ahj.2012.01.017
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background We aimed to study the comparative safety and effectiveness of various antithrombotic treatment strategies among older adults with non-ST elevation myocardial infarction (NSTEMI) and atrial fibrillation (AF). Methods Using the CRUSADE registry linked to longitudinal Medicare claims data, we examined NSTEMI patients aged >= 65 years with a concomitant diagnosis of AF. Multivariable Cox analysis was used to compare risk of rehospitalization for bleeding and a major cardiac composite end point of death, readmission for myocardial infarction, or stroke, according to discharge antithrombotic strategy. Results Among 7619 NSTEMI patients with AF, 29% were discharged on aspirin alone; 37%, on aspirin + clopidogrel; 7%, on warfarin alone; 17%, on aspirin + warfarin; and 10%, on warfarin + aspirin + clopidogrel. There was no difference in predicted stroke risk between groups. By 1 year, 12.2% of patients were rehospitalized for bleeding, and 33.1% had a major cardiac event. Relative to aspirin alone, antithrombotic intensification was associated with increased bleeding risk (aspirin + clopidogrel adjusted HR 1.22, 95% CI 1.03-1.46 and warfarin + aspirin HR 1.46, 95% CI 1.21-1.80). Patients treated with aspirin + clopidogrel + warfarin had the highest observed bleeding risk (HR 1.65, 95% CI 1.30-2.10). One-year risk of the major cardiac end point was similar between groups, although, relative to aspirin only, there was a trend toward lower risk for the warfarin + aspirin group (HR 0.88, 95% CI 0.78-1.00). Conclusions Older NSTEMI patients with AF are at high risk for subsequent bleeding and major cardiac events. Increased antithrombotic management was associated with increased bleeding risk. Further investigation is needed to clarify whether these risks are counterbalanced by reduced thromboembolic events in this population. (Am Heart J 2012;163:720-8.)
引用
收藏
页码:720 / 728
页数:9
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