Direct Oral Anticoagulants (DOAC) and Ticagrelor as an Alternative to Triple Antithrombotic Therapy after an Acute Coronary Syndrome in Patients with Atrial Fibrillation

Introduction: The optimal long-term anticoagulation strategy in patients with atrial fibrillation and acute coronary syndrome (ACS) is not clear. International guidelines recommend triple therapy. However, treatment with oral anticoagulation in combination with a single antiplatelet agent has been shown to reduce the incidence of bleeding compared to triple therapy in the WOEST and PIONEER trials. Starting in the spring of 2015 our center implemented a strategy with DOAC (direct oral anticoagulants; apixaban, rivaroxaban or dabigatran) in combination with ticagrelor without aspirin (dual antithrombotic therapy, DT) in patients with ACS who also had indication for DOAC.
The aim of this study was to evaluate incidence of major bleeding and thrombotic outcomes in this patient group.
Materials and methods: We identified retrospectively all patients who underwent PCI with stent and were on DT upon discharge from our hospitals, between March 2015 and June 2016. Major bleeding was defined in accordance with the HAS-BLED derivation study. Thromboembolic events were defined as a physician’s diagnosis of stroke, transient ischemic attack, acute coronary syndrome or peripheral arterial embolism. The outcomes were compared to a historic cohort treated with warfarin and ticagrelor (WT).
Results: In total, 89 DT patients and 107 WT patients were identified. In the DT group the mean age was 74 ± 9 years and 34.8 % were women, with a mean HAS-BLED bleeding risk score 2.5 ± 1.1 and mean duration of treatment 6.1 ±2.3 months. Three patients in the DT group and 4 patients in the WT group died during the observation time. The incidence of spontaneous major bleeding and thrombotic events were similar between the groups (DT bleeding 5/89 (5.6 %) and thrombosis 2/89 (2.2%) vs WT bleeding 8/107 (7.5 %) and thrombosis 5/107 (4.7 %), NS for both comparisons).
Conclusions: In this single center, retrospective, observational study treatment with DT appears to be a safe alternative to WT in patients with atrial fibrillation.