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Anticoagulation Treatment for Stroke Prevention in Atrial Fibrillation Is Increasing, But Further Improvements Needed
A recent paper by Hsu et  al.(1) assessed antithrombotic treatment among atrial fibrillation (AF) patients. The data, from the American College of Cardiology PINNACLE (Practice Innovation and Clinical Excellence) registry between 2008 and 2012, showed that 61.8% of patients with moderate-to-high stroke risk received anticoagulant therapy with either warfarin or newer direct oral anticoagulants (DOACs). The investigators and an editorial commentary noted the alarming prevalence of aspirin-only treatment despite clear evidence that anticoagulants are superior for prevention of thromboembolism in AF (1,2).
Source: Journal of the American College of Cardiology - November 29, 2016 Category: Cardiology Source Type: research

Reply Anticoagulation Treatment for Stroke Prevention in Atrial Fibrillation Is Increasing, But Further Improvements Needed
We are appreciative of Dr. Brown and colleagues and their interest in our recent paper in theJournal(1) regarding prescription of aspirin instead of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) who are at intermediate-to-high thromboembolic risk in the American College of Cardiology National Cardiovascular Data Registry ’s PINNACLE (Practice Innovation and Clinical Excellence) Registry. They appropriately highlight some of our main findings, including that OAC prescription was selected in 61.8% of patients with a CHADS2 score  ≥2 (meaning 38.2% of patients were treated with aspirin alone) and 5...
Source: Journal of the American College of Cardiology - November 29, 2016 Category: Cardiology Source Type: research

Aspirin Instead of Oral Anticoagulant Prescription in Atrial Fibrillation Patients at Risk for Stroke
ConclusionsIn a large, real-world cardiac outpatient population of AF patients with a moderate to high risk of stroke, more than 1 in 3 were treated with aspirin alone without OAC. Specific patient characteristics predicted prescription of aspirin therapy over OAC.
Source: Journal of the American College of Cardiology - June 21, 2016 Category: Cardiology Source Type: research

Aspirin in Atrial Fibrillation The Clot Thickens ∗
Aspirin is the original “wonder drug,” used in various forms for thousands of years for its analgesic, antipyretic, and anti-inflammatory properties (1), and more recently, for its ability to inhibit platelet aggregation, reducing the risk for occlusive vascular events associated with acute coronary syndromes, transient cerebral ischemic attacks and stroke, and peripheral vascular disease (2).
Source: Journal of the American College of Cardiology - June 21, 2016 Category: Cardiology Source Type: research

Ticagrelor for Prevention of Ischemic Events After Myocardial Infarction in Patients With Peripheral Artery Disease
This study evaluated the efficacy and safety of ticagrelor on major cardiovascular (CV) events and major adverse limb events in patients with PAD and a prior MI.MethodsPEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin—Thrombolysis In Myocardial Infarction 54) randomized 21,162 patients with prior MI (1 to 3 years) to ticagrelor 90 mg twice daily, ticagrelor 60 mg twice daily, or placebo, all on a background of low-dose aspirin. History of PAD was obtained at baseline. Occurrences of major adverse cardiovascular events (...
Source: Journal of the American College of Cardiology - June 7, 2016 Category: Cardiology Source Type: research

The Development of Therapeutics for Peripheral Artery Disease A Unique Cardiovascular Risk Population ∗
Peripheral artery disease (PAD) primarily manifests as occlusive atherosclerosis in the peripheral circulation to the lower extremities (1). Symptomatic patients have either a profound exercise limitation or develop critical limb ischemia, and all of these patients are at heightened risk for major cardiovascular and ischemic limb events (2). Despite a severe morbidity and mortality risk, historically, little attention has been paid to developing targeted therapies to reduce this risk in patients with PAD (3). However, there were early signals that PAD may be responsive to potent antiplatelet therapy in the CAPRIE (Clopidog...
Source: Journal of the American College of Cardiology - June 7, 2016 Category: Cardiology Source Type: research

Reduction in Ischemic Events With Ticagrelor in Diabetic Patients With Prior Myocardial Infarction in PEGASUS–TIMI 54
ConclusionsIn patients with diabetes with prior MI, adding ticagrelor to aspirin significantly reduces the risk of recurrent ischemic events, including cardiovascular and coronary heart disease death. (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562)
Source: Journal of the American College of Cardiology - June 7, 2016 Category: Cardiology Source Type: research

Proton-Pump Inhibitors Reduce Gastrointestinal Events Regardless of Aspirin Dose in Patients Requiring Dual Antiplatelet Therapy
ConclusionsGastroprotection with PPI therapy should be utilized in appropriately selected patients with coronary artery disease requiring DAPT, even if the patients are on low-dose aspirin. (Clopidogrel and the Optimization of Gastrointestinal Events Trial [COGENT]; NCT00557921)
Source: Journal of the American College of Cardiology - April 4, 2016 Category: Cardiology Source Type: research

Gastrointestinal Bleeding in Patients With Atrial Fibrillation Treated With Rivaroxaban or Warfarin ROCKET AF Trial
ConclusionsIn the ROCKET AF trial, rivaroxaban increased GI bleeding compared with warfarin. The absolute fatality rate from GI bleeding was low and similar in both treatment arms. Our results further illustrate the need for minimizing modifiable risk factors for GI bleeding in patients on oral anticoagulation.
Source: Journal of the American College of Cardiology - November 23, 2015 Category: Cardiology Source Type: research

Stroke Risk Stratification in Patients With Atrial Fibrillation Comme Ci, Comme Ça, Plus Ça Change… ∗
There has been a huge increase in academic interest in atrial fibrillation (AF) and particularly its major complication: thromboembolism. This sustained flurry of activity is fueled by the development of better thromboprophylaxis with well-controlled vitamin K antagonist (VKA) anticoagulation rather than antiplatelet therapy or poorly controlled management with VKAs. The emergence of new therapies, such as non-VKA oral anticoagulant agents and left atrial appendage occlusion devices with better net clinical benefit (less strokes, fewer intracranial or life-threatening bleeds, and reduced mortality) than with warfarin or as...
Source: Journal of the American College of Cardiology - October 19, 2015 Category: Cardiology Source Type: research

The Challenge of Getting it Just Right Optimizing Long-Term Antithrombotic Therapy After Acute Coronary Syndrome ∗
Acute coronary syndrome (ACS) is associated with substantial morbidity and mortality (1,2). Initial treatment in the hospital consists of intensive antithrombotic therapy combining parenteral anticoagulation with antiplatelet therapy, whereas secondary prevention relies primarily on dual antiplatelet therapy (DAPT), most commonly aspirin and clopidogrel. However, patients with ACS remain at significant risk of recurrent adverse cardiovascular events (3). Mitigation of this risk requires a delicate balance between escalation of antithrombotic therapy to reduce ischemic events, while hoping the increase in bleeding is tolera...
Source: Journal of the American College of Cardiology - August 10, 2015 Category: Cardiology Source Type: research

Apixaban Plus Mono Versus Dual Antiplatelet Therapy in Acute Coronary Syndromes Insights From the APPRAISE-2 Trial
ConclusionsPost-ACS treatment with apixaban versus placebo showed no efficacy, but it increased bleeding regardless of concomitant therapy with aspirin alone or aspirin plus clopidogrel. (Apixaban for Prevention of Acute Ischemic Events 2 [APPRAISE-2]; NCT00831441)
Source: Journal of the American College of Cardiology - August 10, 2015 Category: Cardiology Source Type: research

Net Clinical Benefit for Oral Anticoagulation, Aspirin, or No Therapy in Nonvalvular Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA 2 DS 2 -VASc Score (Beyond Sex)
Whether to anticoagulate patients with atrial fibrillation (AF) and 1 stroke risk factor (i.e., CHA2DS2-VASc [congestive heart failure, hypertension, age>75 years, diabetes mellitus, stroke, vascular disease, age 65–75 years, and female sex] score = 1 in men, or 2 in women) is controversial, but many studies report ischemic stroke rates of>1.5% per year, even with 1 stroke risk factor (1). We estimated the net clinical benefit (NCB) of aspirin or warfarin compared with no antithrombotic therapy among such patients on the basis of a nationwide Danish cohort, with incident AF diagnosed between 1998 and 2012 (2). Men w...
Source: Journal of the American College of Cardiology - July 20, 2015 Category: Cardiology Source Type: research

Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After Drug-Eluting Stent Implantation The ISAR-TRIPLE Trial
ConclusionsSix weeks of triple therapy was not superior to 6 months with respect to net clinical outcomes. These results suggest that physicians should weigh the trade-off between ischemic and bleeding risk when choosing the shorter or longer duration of triple therapy. (Triple Therapy in Patients on Oral Anticoagulation After Drug Eluting Stent Implantation [ISAR-TRIPLE]; NCT00776633)
Source: Journal of the American College of Cardiology - April 20, 2015 Category: Cardiology Source Type: research

Oral Anticoagulation, Aspirin, or No Therapy in Patients With Nonvalvular AF With 0 or 1 Stroke Risk Factor Based on the CHA 2 DS 2 -VASc Score
ConclusionsLow-risk patients (CHA2DS2-VASc = 0 [male], 1 [female]) have a truly low risk for stroke and bleeding. With 1 additional stroke risk factor (CHA2DS2-VASc = 1 [male], = 2 [female]), there was a significant increase in event rates (particularly mortality) if nonanticoagulated.
Source: Journal of the American College of Cardiology - April 6, 2015 Category: Cardiology Source Type: research

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