Korean Circ J.  2021 May;51(5):409-422. 10.4070/kcj.2020.0407.

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

  • 1Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
  • 2Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, Korea
  • 3Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
  • 4Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
  • 5Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, United Kingdom
  • 6Department of Clinical Medicine, Aalborg University, Aalborg, Denmark


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).
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.
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 CHA2 DS2 -VASc score ≥2. Among various factors, prior intracranial hemorrhage was the most powerful predictor of favoring DAPT use over TAT.
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.


Atrial fibrillation; Percutaneous coronary intervention; Antiplatelet drugs; Anticoagulant drugs


  • Figure 1 Temporal trends of patients with AF undergoing PCI after introduction of NOAC.AF = atrial fibrillation; NOAC = non-vitamin K oral anticoagulant; PCI = percutaneous coronary intervention.

  • Figure 2 Temporal trends of antithrombotic regimens in patients with AF undergoing PCI after introduction of NOAC.AF = atrial fibrillation; DAPT = dual antiplatelet therapy; NOAC = non-vitamin K oral anticoagulant; PCI = percutaneous coronary intervention.

  • Figure 3 Multivariate logistic regression analysis for factors associated with prescriptions of triple therapy.CI = confidence interval; DAPT = dual antiplatelet therapy; OR = odds ratio; TIA = transient ischemic attack.

  • Figure 4 The impact of CHA2DS2-VASc or HAS-BLED scores on the preference of antithrombotic regimens.Multivariate logistic regression analysis based on the study population of 2018. CHA2DS2-VASc score of 0 and HAS-BLED score of 1 served as the reference in each analysis, respectively.CI = confidence interval; DAPT = dual antiplatelet therapy; OR = odds ratio.

Cited by  1 articles

Beginning the Journey to Find Optimal Antithrombotic Regimens for Korean Patients with Atrial Fibrillation after Percutaneous Coronary Intervention
Sung Soo Kim, Hyun Kuk Kim
Korean Circ J. 2021;51(5):423-425.    doi: 10.4070/kcj.2021.0017.


1. Lip GYH, Banerjee A, Boriani G, et al. Antithrombotic therapy for atrial fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018; 154:1121–1201. PMID: 30144419.
2. Lee SR, Choi EK, Kwon S, et al. Effectiveness and safety of contemporary oral anticoagulants among Asians with nonvalvular atrial fibrillation. Stroke. 2019; 50:2245–2249. PMID: 31208303.
3. Michniewicz E, Mlodawska E, Lopatowska P, Tomaszuk-Kazberuk A, Malyszko J. Patients with atrial fibrillation and coronary artery disease - double trouble. Adv Med Sci. 2018; 63:30–35. PMID: 28818746.
4. Choi HI, Ahn JM, Kang SH, et al. Prevalence, management, and long-term (6-year) outcomes of atrial fibrillation among patients receiving drug-eluting coronary stents. JACC Cardiovasc Interv. 2017; 10:1075–1085. PMID: 28527773.
5. Gibson CM, Mehran R, Bode C, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med. 2016; 375:2423–2434. PMID: 27959713.
6. Cannon CP, Bhatt DL, Oldgren J, et al. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med. 2017; 377:1513–1524. PMID: 28844193.
7. Lopes RD, Heizer G, Aronson R, et al. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med. 2019; 380:1509–1524. PMID: 30883055.
8. Vranckx P, Valgimigli M, Eckardt L, et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet. 2019; 394:1335–1343. PMID: 31492505.
9. January CT, Wann LS, Calkins H, et al. 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. J Am Coll Cardiol. 2019; 74:104–132. PMID: 30703431.
10. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019; 40:87–165. PMID: 30165437.
11. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020.
12. Park J, Choi EK, Han KD, et al. Temporal trends in prevalence and antithrombotic treatment among Asians with atrial fibrillation undergoing percutaneous coronary intervention: a nationwide Korean population-based study. PLoS One. 2019; 14:e0209593. PMID: 30645601.
13. Li YG, Lee SR, Choi EK, Lip GY. Stroke prevention in atrial fibrillation: focus on Asian patients. Korean Circ J. 2018; 48:665–684. PMID: 30073805.
14. Kim HK, Tantry US, Smith SC Jr, et al. The East Asian paradox: an updated position statement on the challenges to the current antithrombotic strategy in patients with cardiovascular disease. Thromb Haemost. 2020.
15. Ako J, Okumura K, Nakao K, et al. 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. Circ J. 2019; 83:327–333. PMID: 30643079.
16. Choi EK. Cardiovascular research using the Korean National Health Information Database. Korean Circ J. 2020; 50:754–772. PMID: 32725984.
17. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010; 138:1093–1100. PMID: 20299623.
18. Park J, Kwon S, Choi EK, et al. Validation of diagnostic codes of major clinical outcomes in a National Health Insurance database. Int J Arrhythm. 2019; 20:5.
19. Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013; 381:1107–1115. PMID: 23415013.
20. Lamberts M, Olesen JB, Ruwald MH, et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study. Circulation. 2012; 126:1185–1193. PMID: 22869839.
21. Capodanno D, Huber K, Mehran R, et al. Management of antithrombotic therapy in atrial fibrillation patients undergoing PCI: JACC State-of-the-Art Review. J Am Coll Cardiol. 2019; 74:83–99. PMID: 31272556.
22. Lopes RD, Hong H, Harskamp RE, et al. Safety and efficacy of antithrombotic strategies in patients with atrial fibrillation undergoing percutaneous coronary intervention: a network meta-analysis of randomized controlled trials. JAMA Cardiol. 2019; 4:747–755. PMID: 31215979.
23. Guo Y, Lane DA, Chen Y, Lip GYH. mAF-App II Trial Investigators. Regular bleeding risk assessment associated with reduction in bleeding outcomes: the mAFA-II Randomized Trial. Am J Med. 2020; 133:1195–1202.e2. PMID: 32289310.
24. ACTIVE Writing Group of the ACTIVE Investigators. Connolly S, Pogue J, et al. 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. Lancet. 2006; 367:1903–1912. PMID: 16765759.
25. Shen AY, Yao JF, Brar SS, Jorgensen MB, Chen W. Racial/ethnic differences in the risk of intracranial hemorrhage among patients with atrial fibrillation. J Am Coll Cardiol. 2007; 50:309–315. PMID: 17659197.
26. Fosbol EL, Wang TY, Li S, et al. Warfarin use among older atrial fibrillation patients with non-ST-segment elevation myocardial infarction managed with coronary stenting and dual antiplatelet therapy. Am Heart J. 2013; 166:864–870. PMID: 24176442.
27. Lamberts M, Gislason GH, Olesen JB, et al. Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. J Am Coll Cardiol. 2013; 62:981–989. PMID: 23747760.
28. Sindet-Pedersen C, Lamberts M, Staerk L, et al. Combining oral anticoagulants with platelet inhibitors in patients with atrial fibrillation and coronary disease. J Am Coll Cardiol. 2018; 72:1790–1800. PMID: 30286922.
29. Sindet-Pedersen C, Staerk L, Lamberts M, et al. Use of oral anticoagulants in combination with antiplatelet(s) in atrial fibrillation. Heart. 2018; 104:912–920. PMID: 29092916.
30. Wang YH, Kao HL, Wang CC, Lin SY, Lin FJ. Comparative effectiveness and safety of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome or percutaneous coronary intervention. Acta Cardiol Sin. 2019; 35:508–521. PMID: 31571800.
Full Text Links
  • KCJ
export Copy
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr