© Schattauer 2013 Thrombosis and Haemostasis 110.3/2013 560 Blood Coagulation, Fibrinolysis and Cellular Haemostasis Anticoagulation in patients with atrial fibrillation undergoing coronary stent implantation Anne Bernard 1 ; Laurent Fauchier 1 ; Céline Pellegrin 1 ; Nicolas Clementy 1 ; Christophe Saint Etienne 1 ; Amitava Banerjee 2 ; Djedjiga Naudin 1 ; Denis Angoulvant 1 1 Service de Cardiologie, Pôle Cœur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France; 2 University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK Summary In patients with atrial fibrillation (AF) undergoing coronary stent im- plantation, the optimal antithrombotic strategy is unclear. We evalu- ated whether use of oral anticoagulation (OAC) was associated with any benefit in morbidity or mortality in patients with AF, high risk of thromboembolism (TE) (CHA2DS2-VASC score ≥2) and coronary stent implantation. Among 8,962 unselected patients with AF seen between 2000 and 2010, a total of 2,709 (30%) had coronary artery disease and 417/2,709 (15%) underwent stent implantation while having CHA2DS2-VASC score ≥2. During follow-up (median=650 days), all TE, bleeding episodes, and major adverse cardiac events (i.e. death, acute myocardial infarction, target lesion revascularisation) were rec- orded. At discharge, 97/417 patients (23%) received OAC, which was more likely to be prescribed in patients with permanent AF and in those treated for elective stent implantation. The incidence of out- come event rates was not significantly different in patients treated and those not treated with OAC. However, in multivariate analysis, the lack of OAC at discharge was independently associated with increased risk of death/stroke/systemic TE (relative risk [RR] =2.18, 95% confi- dence interval [CI] 1.02–4.67, p=0.04), with older age (RR =1.12, 1.04–1.20, p=0.003), heart failure (RR =3.26, 1.18–9.01, p=0.02), and history of stroke (RR =18.87, 3.11–111.11, p=0.001). In conclusion, in patients with AF and high thromboembolic risk after stent implan- tation, use of OAC was independently associated with decreased risk of subsequent death/stroke/systemic TE, suggesting that OAC should be systematically used in this patient population. Keywords Atrial fibrillation, oral anticoagulant, antiplatelet agent, coronary stent implantation Correspondence to: Laurent Fauchier, MD Service de Cardiologie B et Laboratoire d’Electrophysiologie Cardiaque Pole Cœur Thorax Vasculaire Hémostase Centre Hospitalier Universitaire Trousseau 37044 Tours, France Tel.: +33 2 47 47 46 50, Fax: +33 2 47 47 59 19 E-mail: lfau@med.univ-tours.fr Received: April 29, 2013 Accepted after major revision: June 26, 2013 Prepublished online: July 11, 2013 doi:10.1160/TH13-04-0351 Thromb Haemost 2013; 110: 560–568 Introduction Atrial fibrillation (AF) is the most common sustained cardiac ar- rhythmia, occurring in 1-2% of the general population. In high- risk patients with AF, oral anticoagulation (OAC) is recommended to reduce the risk of stroke and thromboembolism (TE). Recent guidelines have extended indications for OAC to patients with one or more stroke risk factors (1, 2). Among AF patients, 20-30% have associated coronary artery disease (CAD) and may undergo per- cutaneous coronary intervention (PCI), often with stent implan- tation (3, 4). After implantation, the rate of stent thrombosis is high without dual antiplatelet therapy (5). Current guidelines therefore recommend the use of aspirin–clopidogrel combination therapy for one month after a bare metal stent (BMS) implantation in stable angina; 6-12 months after drug-eluting stent (DES) im- plantation; and for one year in patients after acute coronary syn- drome (ACS), irrespective of the type of revascularisation (1, 5). In AF patients at low risk of stroke (i.e. those with a CHA 2 DS 2 -VASC score ≤1), OAC is not systematically recommended and these pa- tients will usually receive a dual antiplatelet therapy. In subjects with AF at high risk of stroke (i.e. those with a CHA 2 DS 2 -VASC score ≥2), there is theoretically the requirement for long-term OAC. The benefits of prevention of stroke, stent thrombosis fol- lowing PCI and recurrent cardiac ischaemia needs to be balanced with the risk of bleeding with combined antithrombotic therapy. However, the risks and benefits associated with the use of OAC have not been extensively studied in this patient population. The objective of our study was to assess whether the use of OAC at dis- charge was associated with any benefit in morbidity or mortality in patients with AF and a CHA 2 DS 2 -VASC score ≥2 treated with cor- onary stent implantation. Methods We included all patients with a diagnosis of AF or atrial flutter and a CHA 2 DS 2 -VASC score ≥2 who underwent PCI with stenting in the cardiology department of our institution between the years For personal or educational use only. No other uses without permission. All rights reserved. Downloaded from www.thrombosis-online.com on 2014-02-16 | ID: 1000518515 | IP: 193.54.110.33