Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation

作者：Cannon, Christopher P.^*; Bhatt, Deepak L.; Oldgren, Jonas; Lip, Gregory Y. H.; Ellis, Stephen G.; Kimura, Takeshi; Maeng, Michael; Merkely, Bela; Zeymer, Uwe; Gropper, Savion; Nordaby, Matias; Kleine, Eva; Harper, Ruth; Manassie, Jenny; Januzzi, James L.; ten Berg, Jurrien M.; Steg, Gabriel; Hohnloser, Stefan H.

来源：New England Journal of Medicine, 2017, 377(16): 1513-1524.

DOI：10.1056/NEJMoa1708454

• PERCUTANEOUS CORONARY INTERVENTION
• 2011 ACCF/AHA/SCAI GUIDELINE
• ASSOCIATION TASK-FORCE
• TRIPLE THERAPY
• MYOCARDIAL-INFARCTION
• ORAL ANTICOAGULATION
• ANTIPLATELET THERAPY
• CONSENSUS DOCUMENT
• AMERICAN-COLLEGE
• HEART-DISEASE

BACKGROUND @@@ Triple antithrombotic therapy with warfarin plus two antiplatelet agents is the standard of care after percutaneous coronary intervention (PCI) for patients with atrial fibrillation, but this therapy is associated with a high risk of bleeding. @@@ METHODS @@@ In this multicenter trial, we randomly assigned 2725 patients with atrial fibrillation who had undergone PCI to triple therapy with warfarin plus a P2Y(12) inhibitor (clopidogrel or ticagrelor) and aspirin (for 1 to 3 months) (triple-therapy group) or dual therapy with dabigatran (110 mg or 150 mg twice daily) plus a P2Y(12) inhibitor (clopidogrel or ticagrelor) and no aspirin (110-mg and 150-mg dual-therapy groups). Outside the United States, elderly patients (>= 80 years of age; >= 70 years of age in Japan) were randomly assigned to the 110-mg dual-therapy group or the triple-therapy group. The primary end point was a major or clinically relevant nonmajor bleeding event during follow-up (mean follow-up, 14 months). The trial also tested for the noninferiority of dual therapy with dabigatran (both doses combined) to triple therapy with warfarin with respect to the incidence of a composite efficacy end point of thromboembolic events (myocardial infarction, stroke, or systemic embolism), death, or unplanned revascularization. @@@ RESULTS @@@ The incidence of the primary end point was 15.4% in the 110-mg dual-therapy group as compared with 26.9% in the triple-therapy group (hazard ratio, 0.52; 95% confidence interval [CI], 0.42 to 0.63; P<0.001 for noninferiority; P<0.001 for superiority) and 20.2% in the 150-mg dual-therapy group as compared with 25.7% in the corresponding triple-therapy group, which did not include elderly patients outside the United States (hazard ratio, 0.72; 95% CI, 0.58 to 0.88; P<0.001 for noninferiority). The incidence of the composite efficacy end point was 13.7% in the two dual-therapy groups combined as compared with 13.4% in the triple-therapy group (hazard ratio, 1.04; 95% CI, 0.84 to 1.29; P=0.005 for noninferiority). The rate of serious adverse events did not differ significantly among the groups. @@@ CONCLUSIONS @@@ Among patients with atrial fibrillation who had undergone PCI, the risk of bleeding was lower among those who received dual therapy with dabigatran and a P2Y(12) inhibitor than among those who received triple therapy with warfarin, a P2Y(12) inhibitor, and aspirin. Dual therapy was noninferior to triple therapy with respect to the risk of thromboembolic events.

• 出版日期2017-10-19