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Canadian Journal of Cardiology

ANTITHROMBOTIC THERAPIES IN CANADIAN ATRIAL FIBRILLATION PATIENTS WITH CONCOMITANT CORONARY ARTERY DISEASE: INSIGHTS FROM THE CONNECT AF+PCI-I AND -II PROGRAMS

      BACKGROUND

      The Coordinated National Network to Engage Cardiologists in the antithrombotic Treatment of patients with Atrial Fibrillation undergoing Percutaneous Coronary Intervention (CONNECT AF+PCI-I) program provided a snapshot (Nov 2015-Jul 2018) of the antithrombotic management of 467 non-valvular atrial fibrillation (NVAF) patients undergoing PCI in Canada (Bagai et al Can J Cardiol 2018;34:S16). Since then, further randomized clinical trials have supported updated Canadian Cardiovascular Society (CCS) AF and Antiplatelet guideline recommendations for antithrombotic strategies for NVAF and coronary artery disease (CAD) patients undergoing PCI and/or medical management. Thus, an updated quality enhancement assessment in Canadian practice (CONNECT AF+PCI-II) was undertaken.

      METHODS AND RESULTS

      By retrospective chart audit (Aug 2018-Dec 2020), 68 cardiologists from 8 provinces identified 626 patients with NVAF. 37% had stable CAD, 56% had an acute coronary syndrome (ACS) and PCI, and 7% had an ACS and were medically managed. Median age was 76 (25th,75th percentiles 69, 83; 87% ≥65 years); 29% female; 38% diabetes; median CHADS2 score 2 (1, 3); median CHA2DS2-VASc score 4 (3, 5); median HAS-BLED score 3 (2, 3). 73% were receiving oral anticoagulation (OAC) before the index ACS/PCI (apixaban 31%, rivaroxaban 24%, dabigatran 6%, edoxaban 2%, warfarin 10%). Initial antithrombotic therapy after the index ACS/PCI was: 53% triple therapy (OAC+dual antiplatelet therapy [DAPT=ASA+P2Y12 receptor inhibitor], 31% OAC+P2Y12 inhibitor, 9% DAPT, 4% OAC+ASA, 2% OAC alone, and < 1% ASA alone (vs. CONNECT AF+PCI-I: 63% triple therapy, 24% OAC+P2Y12 inhibitor, 12% DAPT, 1% OAC+ASA). The median duration of planned/completed triple therapy was 30 (7, 30) days (vs. CONNECT AF+PCI-I: 1 (1, 3) months; p < 0.0001). Trends in the use of antithrombotic therapy strategies over time (combining data [n=1093] from CONNECT AF+PCI-I and -II) are shown in the Figure. OAC after index ACS/PCI was: apixaban 51%, rivaroxaban 35%, dabigatran 3%, edoxaban 3%, warfarin 8%, none 10%. Overall antiplatelet therapy use was: ASA 66%, clopidogrel 87%, ticagrelor 6%, and prasugrel < 1%. Proton pump inhibitor use was 56% overall, and 69% in patients on ASA. By 1 year, planned antithrombotic therapy was: 76% OAC alone, 8% OAC+P2Y12 inhibitor, 8% OAC+ASA, 4% DAPT, 2% ASA alone, and < 1% triple therapy.

      CONCLUSION

      While triple therapy remains the most common initial antithrombotic strategy used in AF patients undergoing PCI and/or admitted with ACS in Canada, treatment duration has shortened over time. Further, more patients are receiving CCS guideline-recommended OAC+ P2Y12 receptor inhibitor post-PCI compared to previously, and OAC monotherapy 1 year post-ACS/PCI.
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