Antithrombotic Therapy and First Myocardial Infarction in Patients With Atrial Fibrillation

Christina J.Y. Lee; Jannik L. Pallisgaard; Jonas Bjerring Olesen; Nicholas Carlson; Morten Lamberts; Gunnar H. Gislason; Christian Torp-Pedersen; Axel Brandes; Steen E. Husted; Søren P. Johnsen; Morten L. Hansen

doi:10.1016/j.jacc.2017.04.033

Antithrombotic Therapy and First Myocardial Infarction in Patients With Atrial Fibrillation

Christina J.Y. Lee^*, Jannik L. Pallisgaard, Jonas Bjerring Olesen, Nicholas Carlson, Morten Lamberts, Gunnar H. Gislason, Christian Torp-Pedersen, Axel Brandes, Steen E. Husted, Søren P. Johnsen, Morten L. Hansen

^*Corresponding author for this work

Department of Clinical Medicine

17 Citations (Scopus)

Abstract

Background Patients with atrial fibrillation (AF) have increased risk of thromboembolic events such as stroke and myocardial infarction (MI). Although it has been established that the efficacy of anticoagulation is superior to that of antiplatelet agents for stroke prophylaxis in AF, the optimal antithrombotic treatment remains uncertain for primary protection against MI. Objectives The authors investigated the incidence of first-time MI in patients with AF according to antithrombotic treatment and estimated the risk of stroke and bleeding. Methods Subjects with first-time AF diagnosed from 1997 to 2012 without history of coronary artery disease were identified using Danish nationwide administrative registries. Subjects were divided into time varying exposure groups according to antithrombotic treatment. The relative risks of outcomes were estimated by Poisson regression models. Results A total of 71,959 patients (median 75 years of age; females: 47%). At baseline, 37,539 patients (52%) were treated with vitamin K antagonist (VKA) monotherapy, 25,458 (35%) with acetylsalicylic acid (ASA) monotherapy and 8,962 (13%) with dual-therapy (VKA + ASA). The incidence of MI was 3% (n = 2,275). Relative to the VKA-treated group, the associated risk of MI was significantly higher for ASA (incidence rate ratio [IRR]: 1.54; 95% confidence interval [CI]: 1.40 to 1.68) and dual-therapy (IRR: 1.22; 95% CI: 1.06 to 1.40). The bleeding risk was significantly higher for dual-therapy (IRR: 1.93; 95% CI: 1.81 to 2.07). The risk of stroke relative to that of VKA therapy was significantly higher for both ASA (IRR: 2.00; 95% CI: 1.88 to 2.12) and dual-therapy (IRR: 1.30; 95% CI: 1.18 to 1.43). Conclusions VKA monotherapy in patients with AF was associated with a lower risk of first-time MI and stroke than ASA monotherapy. Combination of ASA and VKA therapy was not associated with a lower risk of MI but was associated with increased bleeding risk.

Original language	English
Journal	Journal of the American College of Cardiology
Volume	69
Issue number	24
Pages (from-to)	2901-2909
Number of pages	9
ISSN	0735-1097
DOIs	https://doi.org/10.1016/j.jacc.2017.04.033
Publication status	Published - 20 Jun 2017

Keywords

anticoagulation
aspirin
coronary artery disease
myocardial infarction
warfarin

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10.1016/j.jacc.2017.04.033

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Lee, C. J. Y., Pallisgaard, J. L., Olesen, J. B., Carlson, N., Lamberts, M., Gislason, G. H., Torp-Pedersen, C., Brandes, A., Husted, S. E., Johnsen, S. P., & Hansen, M. L. (2017). Antithrombotic Therapy and First Myocardial Infarction in Patients With Atrial Fibrillation. Journal of the American College of Cardiology, 69(24), 2901-2909. https://doi.org/10.1016/j.jacc.2017.04.033

Lee, CJY, Pallisgaard, JL, Olesen, JB, Carlson, N, Lamberts, M, Gislason, GH, Torp-Pedersen, C, Brandes, A, Husted, SE, Johnsen, SP & Hansen, ML 2017, 'Antithrombotic Therapy and First Myocardial Infarction in Patients With Atrial Fibrillation', Journal of the American College of Cardiology, vol. 69, no. 24, pp. 2901-2909. https://doi.org/10.1016/j.jacc.2017.04.033

@article{4dc84c64b8e4449b9ef24fa3444a9bd6,

title = "Antithrombotic Therapy and First Myocardial Infarction in Patients With Atrial Fibrillation",

abstract = "Background Patients with atrial fibrillation (AF) have increased risk of thromboembolic events such as stroke and myocardial infarction (MI). Although it has been established that the efficacy of anticoagulation is superior to that of antiplatelet agents for stroke prophylaxis in AF, the optimal antithrombotic treatment remains uncertain for primary protection against MI. Objectives The authors investigated the incidence of first-time MI in patients with AF according to antithrombotic treatment and estimated the risk of stroke and bleeding. Methods Subjects with first-time AF diagnosed from 1997 to 2012 without history of coronary artery disease were identified using Danish nationwide administrative registries. Subjects were divided into time varying exposure groups according to antithrombotic treatment. The relative risks of outcomes were estimated by Poisson regression models. Results A total of 71,959 patients (median 75 years of age; females: 47%). At baseline, 37,539 patients (52%) were treated with vitamin K antagonist (VKA) monotherapy, 25,458 (35%) with acetylsalicylic acid (ASA) monotherapy and 8,962 (13%) with dual-therapy (VKA + ASA). The incidence of MI was 3% (n = 2,275). Relative to the VKA-treated group, the associated risk of MI was significantly higher for ASA (incidence rate ratio [IRR]: 1.54; 95% confidence interval [CI]: 1.40 to 1.68) and dual-therapy (IRR: 1.22; 95% CI: 1.06 to 1.40). The bleeding risk was significantly higher for dual-therapy (IRR: 1.93; 95% CI: 1.81 to 2.07). The risk of stroke relative to that of VKA therapy was significantly higher for both ASA (IRR: 2.00; 95% CI: 1.88 to 2.12) and dual-therapy (IRR: 1.30; 95% CI: 1.18 to 1.43). Conclusions VKA monotherapy in patients with AF was associated with a lower risk of first-time MI and stroke than ASA monotherapy. Combination of ASA and VKA therapy was not associated with a lower risk of MI but was associated with increased bleeding risk.",

keywords = "anticoagulation, aspirin, coronary artery disease, myocardial infarction, warfarin",

author = "Lee, {Christina J.Y.} and Pallisgaard, {Jannik L.} and Olesen, {Jonas Bjerring} and Nicholas Carlson and Morten Lamberts and Gislason, {Gunnar H.} and Christian Torp-Pedersen and Axel Brandes and Husted, {Steen E.} and Johnsen, {S{\o}ren P.} and Hansen, {Morten L.}",

year = "2017",

month = jun,

day = "20",

doi = "10.1016/j.jacc.2017.04.033",

language = "English",

volume = "69",

pages = "2901--2909",

journal = "Journal of the American College of Cardiology",

issn = "0735-1097",

publisher = "Elsevier",

number = "24",

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TY - JOUR

T1 - Antithrombotic Therapy and First Myocardial Infarction in Patients With Atrial Fibrillation

AU - Lee, Christina J.Y.

AU - Pallisgaard, Jannik L.

AU - Olesen, Jonas Bjerring

AU - Carlson, Nicholas

AU - Lamberts, Morten

AU - Gislason, Gunnar H.

AU - Torp-Pedersen, Christian

AU - Brandes, Axel

AU - Husted, Steen E.

AU - Johnsen, Søren P.

AU - Hansen, Morten L.

PY - 2017/6/20

Y1 - 2017/6/20

N2 - Background Patients with atrial fibrillation (AF) have increased risk of thromboembolic events such as stroke and myocardial infarction (MI). Although it has been established that the efficacy of anticoagulation is superior to that of antiplatelet agents for stroke prophylaxis in AF, the optimal antithrombotic treatment remains uncertain for primary protection against MI. Objectives The authors investigated the incidence of first-time MI in patients with AF according to antithrombotic treatment and estimated the risk of stroke and bleeding. Methods Subjects with first-time AF diagnosed from 1997 to 2012 without history of coronary artery disease were identified using Danish nationwide administrative registries. Subjects were divided into time varying exposure groups according to antithrombotic treatment. The relative risks of outcomes were estimated by Poisson regression models. Results A total of 71,959 patients (median 75 years of age; females: 47%). At baseline, 37,539 patients (52%) were treated with vitamin K antagonist (VKA) monotherapy, 25,458 (35%) with acetylsalicylic acid (ASA) monotherapy and 8,962 (13%) with dual-therapy (VKA + ASA). The incidence of MI was 3% (n = 2,275). Relative to the VKA-treated group, the associated risk of MI was significantly higher for ASA (incidence rate ratio [IRR]: 1.54; 95% confidence interval [CI]: 1.40 to 1.68) and dual-therapy (IRR: 1.22; 95% CI: 1.06 to 1.40). The bleeding risk was significantly higher for dual-therapy (IRR: 1.93; 95% CI: 1.81 to 2.07). The risk of stroke relative to that of VKA therapy was significantly higher for both ASA (IRR: 2.00; 95% CI: 1.88 to 2.12) and dual-therapy (IRR: 1.30; 95% CI: 1.18 to 1.43). Conclusions VKA monotherapy in patients with AF was associated with a lower risk of first-time MI and stroke than ASA monotherapy. Combination of ASA and VKA therapy was not associated with a lower risk of MI but was associated with increased bleeding risk.

AB - Background Patients with atrial fibrillation (AF) have increased risk of thromboembolic events such as stroke and myocardial infarction (MI). Although it has been established that the efficacy of anticoagulation is superior to that of antiplatelet agents for stroke prophylaxis in AF, the optimal antithrombotic treatment remains uncertain for primary protection against MI. Objectives The authors investigated the incidence of first-time MI in patients with AF according to antithrombotic treatment and estimated the risk of stroke and bleeding. Methods Subjects with first-time AF diagnosed from 1997 to 2012 without history of coronary artery disease were identified using Danish nationwide administrative registries. Subjects were divided into time varying exposure groups according to antithrombotic treatment. The relative risks of outcomes were estimated by Poisson regression models. Results A total of 71,959 patients (median 75 years of age; females: 47%). At baseline, 37,539 patients (52%) were treated with vitamin K antagonist (VKA) monotherapy, 25,458 (35%) with acetylsalicylic acid (ASA) monotherapy and 8,962 (13%) with dual-therapy (VKA + ASA). The incidence of MI was 3% (n = 2,275). Relative to the VKA-treated group, the associated risk of MI was significantly higher for ASA (incidence rate ratio [IRR]: 1.54; 95% confidence interval [CI]: 1.40 to 1.68) and dual-therapy (IRR: 1.22; 95% CI: 1.06 to 1.40). The bleeding risk was significantly higher for dual-therapy (IRR: 1.93; 95% CI: 1.81 to 2.07). The risk of stroke relative to that of VKA therapy was significantly higher for both ASA (IRR: 2.00; 95% CI: 1.88 to 2.12) and dual-therapy (IRR: 1.30; 95% CI: 1.18 to 1.43). Conclusions VKA monotherapy in patients with AF was associated with a lower risk of first-time MI and stroke than ASA monotherapy. Combination of ASA and VKA therapy was not associated with a lower risk of MI but was associated with increased bleeding risk.

KW - anticoagulation

KW - aspirin

KW - coronary artery disease

KW - myocardial infarction

KW - warfarin

U2 - 10.1016/j.jacc.2017.04.033

DO - 10.1016/j.jacc.2017.04.033

M3 - Journal article

C2 - 28619189

AN - SCOPUS:85020645313

SN - 0735-1097

VL - 69

SP - 2901

EP - 2909

JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

IS - 24

ER -

Antithrombotic Therapy and First Myocardial Infarction in Patients With Atrial Fibrillation

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Keywords

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