Impact of Non-Vitamin K Antagonist Oral Anticoagulants on the Change of Antithrombotic Regimens in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

다국어 초록 (Multilingual Abstract)

Background and Objectives: Antithrombotic therapy after percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) has changed in recent years with new data from large randomized trials and updates to clinical guidelines. This study aimed to investigate the trends in periprocedural antithrombotic regimens in Korean patients with AF undergoing PCI with non-vitamin K antagonist oral anticoagulants (NOACs).
Methods: Using the claims database of the Health Insurance Review and Assessment during 2013–2018, 27,594 patients with AF undergoing PCI were identified. The annual prevalence of PCI and prescriptions of each antithrombotic agent, including antiplatelet agents and oral anticoagulants, within 30 days after PCI were investigated.
Results: During 2013–2018, the number of patients with AF undergoing PCI increased up to 1.3-fold (from 3,913 to 5,075 patients per year). After the introduction of NOACs, the proportion of dual antiplatelet therapy (DAPT) decreased from 71.9% to 49.8% but still occupied the largest proportion among antithrombotic regimens. Triple antithrombotic therapy (TAT) use increased from 25.4% to 46.0%, and NOAC has rapidly replaced warfarin as the oral anticoagulant of choice. TAT was preferred to DAPT for patients with CHA2DS2-VASc score ≥2. Among various factors, prior intracranial hemorrhage was the most powerful predictor of favoring DAPT use over TAT.


Conclusion: Since the introduction of NOACs, the patterns of periprocedural antithrombotic regimens have changed rapidly toward more use of TAT, specifically with NOAC-based regimen. Appropriate stroke prevention with oral anticoagulants is still underutilized in patients with AF undergoing PCI in Korea.

참고문헌 (Reference)

1 Fosbol EL, "Warfarin use among older atrial fibrillation patients with non-ST-segment elevation myocardial infarction managed with coronary stenting and dual antiplatelet therapy" 166 : 864-870, 2013

2 Park J, "Validation of diagnostic codes of major clinical outcomes in a National Health Insurance database" 20 : 5-, 2019

3 Sindet-Pedersen C, "Use of oral anticoagulants in combination with antiplatelet(s)in atrial fibrillation" 104 : 912-920, 2018

4 Dewilde WJ, "Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention : an open-label, randomised, controlled trial" 381 : 1107-1115, 2013

5 Kim HK, "The East Asian paradox : an updated position statement on the challenges to the current antithrombotic strategy in patients with cardiovascular disease" 2020

6 Park J, "Temporal trends in prevalence and antithrombotic treatment among Asians with atrial fibrillation undergoing percutaneous coronary intervention : a nationwide Korean population-based study" 14 : e0209593-, 2019

7 Yan-Guang Li, "Stroke Prevention in Atrial Fibrillation: Focus on Asian Patients" 대한심장학회 48 (48): 665-684, 2018

8 Lopes RD, "Safety and efficacy of antithrombotic strategies in patients with atrial fibrillation undergoing percutaneous coronary intervention : a network meta-analysis of randomized controlled trials" 4 : 747-755, 2019

9 Guo Y, "Regular bleeding risk assessment associated with reduction in bleeding outcomes : the mAFA-II Randomized Trial" 133 : 1195-1202, 2020

10 Shen AY, "Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation" 50 : 309-315, 2007

11 Gibson CM, "Prevention of bleeding in patients with atrial fibrillation undergoing PCI" 375 : 2423-2434, 2016

12 Choi HI, "Prevalence, management, and long-term(6-year)outcomes of atrial fibrillation among patients receiving drug-eluting coronary stents" 10 : 1075-1085, 2017

13 Michniewicz E, "Patients with atrial fibrillation and coronary artery disease-double trouble" 63 : 30-35, 2018

14 Lamberts M, "Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention" 62 : 981-989, 2013

15 Capodanno D, "Management of antithrombotic therapy in atrial fibrillation patients undergoing PCI : JACC State-of-the-Art Review" 74 : 83-99, 2019

16 Lee SR, "Effectiveness and safety of contemporary oral anticoagulants among Asians with nonvalvular atrial fibrillation" 50 : 2245-2249, 2019

17 Vranckx P, "Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation(ENTRUSTAF PCI) : a randomised, open-label, phase 3b trial" 394 : 1335-1343, 2019

18 Cannon CP, "Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation" 377 : 1513-1524, 2017

19 Ako J, "Dual anti-thrombotic therapy with dabigatran after percutaneous coronary intervention in atrial fibrillation-Japanese and East-Asian Subgroup Analysis of the RE-DUAL PCI Trial" 83 : 327-333, 2019

20 Wang YH, "Comparative effectiveness and safety of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome or percutaneous coronary intervention" 35 : 508-521, 2019

21 Sindet-Pedersen C, "Combining oral anticoagulants with platelet inhibitors in patients with atrial fibrillation and coronary disease" 72 : 1790-1800, 2018

22 ACTIVE Writing Group of the ACTIVE Investigators, "Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events(ACTIVE W) : a randomised controlled trial" 367 : 1903-1912, 2006

23 Eue-Keun Choi, "Cardiovascular Research Using the Korean National Health Information Database" 대한심장학회 50 (50): 754-772, 2020

24 Lamberts M, "Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention : a nationwide cohort study" 126 : 1185-1193, 2012

25 Lip GYH, "Antithrombotic therapy for atrial fibrillation : CHEST Guideline and Expert Panel Report" 154 : 1121-1201, 2018

26 Lopes RD, "Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation" 380 : 1509-1524, 2019

27 Pisters R, "A novel user-friendly score(HAS-BLED)to assess 1-year risk of major bleeding in patients with atrial fibrillation : the Euro Heart Survey" 138 : 1093-1100, 2010

28 Hindricks G, "2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS)" 2020

29 January CT, "2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation : a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society" 74 : 104-132, 2019

30 Neumann FJ, "2018 ESC/EACTS Guidelines on myocardial revascularization" 40 : 87-165, 2019