J Korean Med Sci.  2024 Jun;39(24):e191. 10.3346/jkms.2024.39.e191.

Optimal Antithrombotic Therapy Beyond 1-Year After Coronary Revascularization in Patients With Atrial Fibrillation

• Kim J
• Kang D
• Kim H
• Park H
• Park TK
• Lee JM
• Yang JH
• Song YB
• Choi JH
• Choi SH
• Gwon HC
• Guallar E
• Cho J
• Hahn JY

• KMID: 2556687
• DOI: http://doi.org/10.3346/jkms.2024.39.e191

Abstract

Background
Currently, non-vitamin K-antagonist oral anticoagulant (NOAC) monotherapy has been suggested as the optimal antithrombotic therapy for atrial fibrillation (AF) beyond one year after coronary revascularization. The aim of this study was to compare the outcomes between NOAC monotherapy and NOAC plus antiplatelet combination therapy using realworld data.
Methods
Between 2015 and 2020, patients with AF who had received NOACs beyond one year after coronary revascularization were enrolled from Korean national insurance data. We emulated a pragmatic sequence of trials between the NOAC monotherapy and the antiplatelet combination therapy followed by propensity score matching. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs), a composite of all-cause death, myocardial infarction, and stroke.
Results
Among 206,407 person-trials from 4,465 individuals, we compared 3,275 pairs of the monotherapy and the matched combination therapy. During a median follow-up of 1.24 years, the incidence rate of MACCE was 19.4% and 20.0% per patient-year in the monotherapy group and the antiplatelet combination group, respectively (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.88–1.05; P = 0.422). Compared with the antiplatelet combination group, the monotherapy group had a significantly lower incidence rate of major bleeding, defined as intracranial bleeding or gastrointestinal bleeding requiring hospitalization (2.8% vs. 3.6% per patient-year; HR, 0.78; 95% CI, 0.62–0.97; P = 0.024).
Conclusion
As an antithrombotic therapy for AF beyond one year after coronary revascularization, NOAC monotherapy was associated with a similar risk of MACCE and a lower risk of major bleeding compared to NOAC plus antiplatelet combination therapy.

Keyword

Atrial Fibrillation; Coronary Artery Disease; Anticoagulation

Figure

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  Fig. 1 Study flow.NOAC = non-vitamin K-antagonist oral anticoagulant, AF = atrial fibrillation, MACCE = major adverse cardiac and cerebrovascular event.

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  Fig. 2 Clinical outcomes between NOAC monotherapy and NOAC plus antiplatelet combination therapy. (A) MACCE, a composite of all-cause death, myocardial infarction, and stroke; (B) Major bleeding.NOAC = non-vitamin K-antagonist oral anticoagulant, MACCE = major adverse cardiac and cerebrovascular event.

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  Fig. 3 Subgroup analysis.HR = hazard ratio, MACCE = major adverse cardiac and cerebrovascular event, CI = confidence interval, NOAC = non-vitamin K-antagonist oral anticoagulant.

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