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Original Research: THROMBOSIS |

Increased Major Bleeding Complications Related to Triple Antithrombotic Therapy Usage in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Artery Stenting

Sergio Manzano-Fernández, MD; Francisco J. Pastor, MD; Francisco Marín, MD, PhD; Francisco Cambronero, MD; Cesar Caro, MD; Domingo A. Pascual-Figal, MD, PhD; Iris P. Garrido, MD; Eduardo Pinar, MD, PhD; Mariano Valdés, MD, PhD; Gregory Y. H. Lip, MD; for the CREDO Investigators; for the SYNERGY Trial Investigators; for the GRACE Investigators
Author and Funding Information

*From the Department of Cardiology (Drs. Manzano-Fernández, Pastor, Marín, Cambronero, Caro, Pascual-Figal, Garrido, Pinar, and Valdés), University Hospital Virgen de la Arrixaca, Murcia, Spain; and University Department of Medicine (Dr. Lip), City Hospital, Birmingham, UK.

Correspondence to: Gregory Y. H. Lip, MD, University Department of Medicine, City Hospital, Birmingham B18 7QH, UK; e-mail: g.y.h.lip@bham.ac.uk


The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2008;134(3):559-567. doi:10.1378/chest.08-0350
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Background:  The optimal antithrombotic therapy strategy for atrial fibrillation (AF) patients who undergo percutaneous coronary intervention with stent implantation (PCI-S) is unknown. We assessed the safety of antithrombotic therapy strategies in AF patients with indication for oral anticoagulation (OAC) undergoing PCI-S.

Methods:  We studied consecutive AF patients with indication for OAC who underwent PCI-S. We compared patients that received triple antithrombotic therapy (TT) [aspirin, clopidogrel, and coumadin] against other regimes (non-TT) after PCI-S. The primary end point was defined as the occurrence of major bleeding complications that were termed as early major bleeding (EMB) [≤ 48 h] or late major bleeding (LMB) [> 48 h]. Clinical follow-up was performed, and complications were recorded.

Results:  We studied 104 patients (mean age ± SD, 72 ± 8 years; 70% men); TT was used in 51 patients (49%). TT was associated with a higher incidence of LMB (21.6% vs non-TT, 3.8%; p = 0.006) but not of EMB (5.8% vs non-TT, 11.3%; p = 0.33). In multivariate analyses, glycoprotein (GP) IIb/IIIa inhibitor use (hazard ratio [HR], 13.5; 95% confidence interval [CI], 1.7 to 108.3; p = 0.014) and PCI-S of three vessels or left main artery disease (HR, 7.9; 95% CI, 1.6 to 39.2; p = 0.01) were independent predictors for EMB. TT use (HR, 7.1; 95% CI, 1.5 to 32.4; p = 0.012), the occurrence of EMB (HR, 6.7; 95% CI, 1.8 to 25.3; p = 0.005), and baseline anemia (HR, 3.8; 95% CI, 1.2 to 12.5; p = 0.027) were independent predictors for LMB. No differences in major cardiovascular events were observed in patients treated with TT vs non-TT (25.5% vs 21.0%; p = 0.53).

Conclusion:  A high rate of major bleeding is observed in AF patients with indication for OAC undergoing PCI-S who receive TT. GP IIb/IIIa inhibitor use and multivessel/left main artery disease during PCI-S were independent predictors for EMB, while TT use, occurrence of EMB, and baseline anemia were independent predictors for LMB.

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