Évaluation de l'efficacité et de la sécurité de l'association anticoagulant-antiagrégant plaquettaire chez les patients ayant bénéficié d'une angioplastie coronaire et nécessitant une anti-coagulation curative au long cours pour un flutter ou une fibrillation atriale avec un score de CHA2DS2-VASc ≥1

Abstract : Introduction: 5 to 10% of patients with supra ventricular arythmia (atrial fibrillation, atrial flutter) undergo percutaneous coronary intervention. To prevent stent thrombosis and embolic complications of atrial fibrillation, dual antiplatelet therapy and oral anticoagulant therapy are recommended. The combination of both antithrombotics treatments, increase risks of bleedings, particularly with patients seen in real life, older and older, with multiple co-morbidities. The european society of cardiolology guidelines, represent a low level of evidence because they are based on few of clinical randomized trials, for which populations were selected, with low ischemic and bleeding risk. The main objective of this study, was to estimate, in real life, efficacy and safety for the combination of antiplatelet therapy and oral anticoagulant in patients with atrial fibrillation or flutter (CHA2DS2-VASc  1), undergoing percutaneous coronary intervention. Materiel and methods: This was a prospective, nonrandomized, observational, open label, and monocentric study performed to the university hospital North Marseille. Patients included received the association of antiplatelet and oral anticoagulant therapies, after percutaneous coronary intervention with stent placement in a context of atrial flutter or fibrillation with CHA2DS2-VASc 1. Patients were assigned to one of two groups: one taking double antithrombotic therapy with oral anticoagulant and Clopidogrel (75 mg once daily) and the other taking triple antithrombotic oral anticoagulant, Clopidogrel (75 mg once daily) and Aspirine (75-100 mg once daily). The primary endpoint was major adverse cardiovascular events (cardiovascular death, Stroke, urgent revascularization, myocardial infarction) and major bleeding events (BARC > 3) at one month. Results: 219 patients were included from April 2015 to July 2018. 166 (75.8%) patients were on the triple therapy group and 53 (24.2%) patients were on the double therapy group. At 1 month, MACE had occurred in 7,8% of patients with no statically significant difference between triple therapy and double therapy (6.8% vs 11.1% ; p=0.35) and there were 15,5% major bleeding events (BARC >3) with no statically significant difference between two groups (16,8% vs 11,1% ; p=0.49). At one year, MACE were observed in 25.7% of patients and major bleedings events rate was 22.8%. Patients taking triple therapy had more bleeding events (BARC 1 to 5) than patients taking double therapy (44.1% vs 26.7%; p=0.04). Discussion: During the first months, the incidence of major bleeding events was particularly high on the triple therapy group whereas, the incidence of ischemic events was constant over the first year of follow. This is the first real life study, evaluating such an old and co-morbide population, mainly composed of acute coronary syndrome. These outcomes suggested more major bleeding events on triple therapy group, and more MACE on double therapy group. The antithrombotic strategy must be individualized after evaluation of the benefit/risk balance. Conclusion: It is crucial to assess benefit/risk balance in order to tailor the antithrombotic strategy, which need to be explained to the patients.
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Thibaut Dabry. Évaluation de l'efficacité et de la sécurité de l'association anticoagulant-antiagrégant plaquettaire chez les patients ayant bénéficié d'une angioplastie coronaire et nécessitant une anti-coagulation curative au long cours pour un flutter ou une fibrillation atriale avec un score de CHA2DS2-VASc ≥1. Sciences du Vivant [q-bio]. 2018. ⟨dumas-02088967⟩

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