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Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction.
Am Heart J 2012; 163(4):720-8AH

Abstract

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.

Authors+Show Affiliations

Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA. emil.fosbol@duke.eduNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

22520540

Citation

Fosbol, Emil L., et al. "Safety and Effectiveness of Antithrombotic Strategies in Older Adult Patients With Atrial Fibrillation and non-ST Elevation Myocardial Infarction." American Heart Journal, vol. 163, no. 4, 2012, pp. 720-8.
Fosbol EL, Wang TY, Li S, et al. Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction. Am Heart J. 2012;163(4):720-8.
Fosbol, E. L., Wang, T. Y., Li, S., Piccini, J. P., Lopes, R. D., Shah, B., ... Peterson, E. D. (2012). Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction. American Heart Journal, 163(4), pp. 720-8. doi:10.1016/j.ahj.2012.01.017.
Fosbol EL, et al. Safety and Effectiveness of Antithrombotic Strategies in Older Adult Patients With Atrial Fibrillation and non-ST Elevation Myocardial Infarction. Am Heart J. 2012;163(4):720-8. PubMed PMID: 22520540.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction. AU - Fosbol,Emil L, AU - Wang,Tracy Y, AU - Li,Shuang, AU - Piccini,Jonathan P, AU - Lopes,Renato D, AU - Shah,Bimal, AU - Mills,Roger M, AU - Klaskala,Winslow, AU - Alexander,Karen P, AU - Thomas,Laine, AU - Roe,Matthew T, AU - Peterson,Eric D, Y1 - 2012/03/14/ PY - 2011/12/09/received PY - 2012/01/24/accepted PY - 2012/4/24/entrez PY - 2012/4/24/pubmed PY - 2012/6/13/medline SP - 720 EP - 8 JF - American heart journal JO - Am. Heart J. VL - 163 IS - 4 N2 - 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. SN - 1097-6744 UR - https://www.unboundmedicine.com/medline/citation/22520540/Safety_and_effectiveness_of_antithrombotic_strategies_in_older_adult_patients_with_atrial_fibrillation_and_non_ST_elevation_myocardial_infarction_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0002-8703(12)00064-6 DB - PRIME DP - Unbound Medicine ER -