RESUMO
PURPOSE: Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2Y12 receptor inhibitor, and aspirin for 1 week or until hospital discharge in patients with atrial fibrillation (AF) undergoing PCI, and up to 4 weeks in individuals considered to be at high-risk for ischemic events, followed by discontinuation of aspirin and continuation of OAC and a P2Y12 inhibitor for up to 12 months. METHODS: We examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2Y12 inhibitor with and without aspirin in AF patients undergoing PCI with stenting. RESULTS: Data comparing dual therapy with OAC and a P2Y12 inhibitor alone to triple therapy with OAC, a P2Y12 inhibitor, and aspirin with respect to the risks of MACEs, including stent thrombosis within the first 30 days, are underpowered and inconclusive. The addition of aspirin does not appear to be associated with a decreased risk of ischemic events, even in patients with high-risk CHA2DS2-VASc scores, but does significantly increase bleeding hazards. The increased safety of newer generation drug-eluting stents may have further minimized any theoretical anti-ischemic benefits of aspirin. The possible attenuation of the pleiotropic effects of concomitant cardiovascular medications by aspirin may also have been a contributing factor. CONCLUSION: The addition of aspirin to OAC and a P2Y12 inhibitor is likely associated with a net clinical harm in patients with AF who undergo PCI with stenting, even within the first 1-4 weeks after PCI. Revisiting the guideline recommendations to administer aspirin in this timeframe may be warranted.
RESUMO
Background: Studies have shown that women with acute myocardial infarction (AMI) have a higher prevalence of unfavorable social variables then men and have a worse outcome. Less is known regarding the impact of these social variables on 30-day readmission after AMI. Materials and Methods: We analyzed adult patients with AMI enrolled in a Quality Improvement Program intended to improve the peri-discharge care of patients with an AMI, and decrease all-cause 30-day unplanned readmissions. We compared clinical and social variables by gender. Multivariate logistic regression, with separate adjustment for clinical and for social variable, was used to measure adjusted odds for readmission by gender. Results: Among 208 patients included in our project 68 (32.7%) were women. Only 30.9% of women were married or had domestic partner at the time of the interview and only 16.2% were employed. Nearly half of women (48.5%) needed help with medical care, and 39.7% of women did not speak English as their first language. These variables were significantly different by gender. Rates of 30-day readmissions were higher in women than men (22.1% vs. 7.8%, p = 0.024). After adjusting for clinical variables this difference by gender in 30-day readmissions remained significant (odds ratio [OR] 3.34 95% confidence interval [CI] 1.1-11.1, p = 0.049). However, when adjusting for social variables, this difference was no longer noted (OR 0.87 95% CI 0.27-2.78, p = 0.822). Conclusion: Women with AMI are more likely than men to have unfavorable social factors that can impact recovery from AMI and women have a higher 30-day readmission rate. The higher 30-day readmissions in women appears to be influenced by these social factors. Health care interventions aimed at reducing 30-day readmission after AMI should focus on eliciting a detailed social history and providing aid for those requiring additional social support at home.