Triple therapy leads to higher rates of major bleeding in older patients with AF and MI

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A comparison of treatment options for older patients with atrial fibrillation who had an MI and underwent PCI found that the rates for major adverse cardiac events were similar among those receiving triple therapy or dual antiplatelet therapy. However, patients receiving triple therapy had higher rates of major bleeding.

Of the nearly 5,000 patients included in the analysis, 27.6 percent received triple therapy, which consisted of warfarin, aspirin and clopidogrel. Results were published online in the  Journal of the American College of Cardiology on Aug. 3.

Lead researcher Connie N. Hess, MD, MHS, of the Duke Clinical Research Institute, and colleagues noted that guidelines and evidence are unclear as to the optimal treatment for acute MI patients with atrial fibrillation who are treated with PCI.

In this analysis, they linked Medicare administrative claims with data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines. They identified 4,959 patients who were at least 65 years old and analyzed information from more than 400 hospitals from Jan. 1, 2007, through Dec. 31, 2010.  

The researchers found patients receiving triple therapy were more likely to be male and have had a history of PCI or CABG, prior stroke and recent atrial fibrillation or atrial flutter. The use of triple therapy increased with higher predicted stroke risk but not with higher predicted bleeding risk.

Two years after hospital discharge, 32.6 percent of patients in the triple therapy group and 32.7 percent of patients in the dual antiplatelet group had major adverse cardiac events, which were defined as death or readmission for MI or stroke.

During that same time period, there were similar rates in the triple therapy and dual antiplatelet therapy groups for all-cause mortality (23.8 percent vs. 24.8 percent), MI readmission (8.5 percent vs. 8.1 percent) and stroke readmission (4.7 percent vs. 5.3 percent).

Within two years of discharge, 17.6 percent of patients in the triple therapy group and 11 percent of patients in the dual antiplatelet group had been readmitted because of bleeding complications.

“The increased risk of bleeding without apparent benefit of triple therapy observed in this study suggests that clinicians should carefully consider the risk-to-benefit ratio of triple therapy use in older atrial fibrillation patients who have had a heart attack treated with angioplasty,” Hess said in a  news release. “Further prospective studies of different combinations of anti-clotting agents are needed to define the optimal treatment regimen for this population.”