Antiplatelet Therapy for Stable Coronary Artery Disease in Atrial Fibrillation Patients Taking an Oral Anticoagulant: A Nationwide Cohort Study
BACKGROUND—The optimal long-term antithrombotic treatment of patients with coexisting atrial fibrillation and stable coronary artery disease is unresolved, and commonly, a single antiplatelet agent is added to oral anticoagulation. We investigated the effectiveness and safety of adding antiplatelet...
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| Veröffentlicht in: | Circulation (New York, N.Y.) N.Y.), 2014-04, Vol.129 (15), p.1577-1585 |
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| creator | Lamberts, Morten Gislason, Gunnar H Lip, Gregory Y.H Lassen, Jens Flensted Olesen, Jonas Bjerring Mikkelsen, Anders P Sørensen, Rikke Køber, Lars Torp-Pedersen, Christian Hansen, Morten Lock |
| description | BACKGROUND—The optimal long-term antithrombotic treatment of patients with coexisting atrial fibrillation and stable coronary artery disease is unresolved, and commonly, a single antiplatelet agent is added to oral anticoagulation. We investigated the effectiveness and safety of adding antiplatelet therapy to vitamin K antagonist (VKA) in atrial fibrillation patents with stable coronary artery disease.
METHODS AND RESULTS—Atrial fibrillation patients with stable coronary artery disease (defined as 12 months from an acute coronary event) between 2002 and 2011 were identified. The subsequent risk of cardiovascular events and serious bleeding events (those that required hospitalization) was examined with adjusted Cox regression models according to ongoing antithrombotic therapy. A total of 8700 patients were included (mean age, 74.2 years; 38% women). During a mean follow-up of 3.3 years, crude incidence rates were 7.2, 3.8, and 4.0 events per 100 person-years for myocardial infarction/coronary death, thromboembolism, and serious bleeding, respectively. Relative to VKA monotherapy, the risk of myocardial infarction/coronary death was similar for VKA plus aspirin (hazard ratio, 1.12 [95% confidence interval, 0.94–1.34]) and VKA plus clopidogrel (hazard ratio, 1.53 [95% confidence interval, 0.93–2.52]). The risk of thromboembolism was comparable in all regimens that included VKA, whereas the risk of bleeding increased when aspirin (hazard ratio, 1.50 [95% confidence interval, 1.23–1.82]) or clopidogrel (hazard ratio, 1.84 [95% confidence interval, 1.11–3.06]) was added to VKA.
CONCLUSIONS—In atrial fibrillation patients with stable coronary artery disease, the addition of antiplatelet therapy to VKA therapy is not associated with a reduction in risk of recurrent coronary events or thromboembolism, whereas risk of bleeding is increased significantly. The common practice of adding antiplatelet therapy to oral VKA anticoagulation in patients with atrial fibrillation and stable coronary artery disease warrants reassessment. |
| doi_str_mv | 10.1161/CIRCULATIONAHA.113.004834 |
| format | Article |
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METHODS AND RESULTS—Atrial fibrillation patients with stable coronary artery disease (defined as 12 months from an acute coronary event) between 2002 and 2011 were identified. The subsequent risk of cardiovascular events and serious bleeding events (those that required hospitalization) was examined with adjusted Cox regression models according to ongoing antithrombotic therapy. A total of 8700 patients were included (mean age, 74.2 years; 38% women). During a mean follow-up of 3.3 years, crude incidence rates were 7.2, 3.8, and 4.0 events per 100 person-years for myocardial infarction/coronary death, thromboembolism, and serious bleeding, respectively. Relative to VKA monotherapy, the risk of myocardial infarction/coronary death was similar for VKA plus aspirin (hazard ratio, 1.12 [95% confidence interval, 0.94–1.34]) and VKA plus clopidogrel (hazard ratio, 1.53 [95% confidence interval, 0.93–2.52]). The risk of thromboembolism was comparable in all regimens that included VKA, whereas the risk of bleeding increased when aspirin (hazard ratio, 1.50 [95% confidence interval, 1.23–1.82]) or clopidogrel (hazard ratio, 1.84 [95% confidence interval, 1.11–3.06]) was added to VKA.
CONCLUSIONS—In atrial fibrillation patients with stable coronary artery disease, the addition of antiplatelet therapy to VKA therapy is not associated with a reduction in risk of recurrent coronary events or thromboembolism, whereas risk of bleeding is increased significantly. The common practice of adding antiplatelet therapy to oral VKA anticoagulation in patients with atrial fibrillation and stable coronary artery disease warrants reassessment.</description><identifier>ISSN: 0009-7322</identifier><identifier>EISSN: 1524-4539</identifier><identifier>DOI: 10.1161/CIRCULATIONAHA.113.004834</identifier><identifier>PMID: 24470482</identifier><identifier>CODEN: CIRCAZ</identifier><language>eng</language><publisher>Hagerstown, MD: by the American College of Cardiology Foundation and the American Heart Association, Inc</publisher><subject><![CDATA[Aged ; Aged, 80 and over ; Anticoagulants - administration & dosage ; Anticoagulants - adverse effects ; Aspirin - administration & dosage ; Aspirin - adverse effects ; Atrial Fibrillation - drug therapy ; Atrial Fibrillation - mortality ; Biological and medical sciences ; Blood and lymphatic vessels ; Cardiac dysrhythmias ; Cardiology. Vascular system ; Cohort Studies ; Comorbidity ; Coronary Artery Disease - drug therapy ; Coronary Artery Disease - mortality ; Coronary heart disease ; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous ; Drug Therapy, Combination ; Female ; Heart ; Hemorrhage - mortality ; Humans ; Incidence ; Male ; Medical sciences ; Middle Aged ; Myocardial Infarction - mortality ; Neurology ; Phenprocoumon - administration & dosage ; Phenprocoumon - adverse effects ; Platelet Aggregation Inhibitors - administration & dosage ; Platelet Aggregation Inhibitors - adverse effects ; Risk Factors ; Stroke - mortality ; Ticlopidine - administration & dosage ; Ticlopidine - adverse effects ; Ticlopidine - analogs & derivatives ; Vascular diseases and vascular malformations of the nervous system ; Vitamin K - antagonists & inhibitors ; Warfarin - administration & dosage ; Warfarin - adverse effects]]></subject><ispartof>Circulation (New York, N.Y.), 2014-04, Vol.129 (15), p.1577-1585</ispartof><rights>2014 by the American College of Cardiology Foundation and the American Heart Association, Inc.</rights><rights>2015 INIST-CNRS</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c3454-e93ae2384aa68f5fef76371747d1c1bc42b6fceee93870982b554625136ca4bd3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,776,780,3674,27901,27902</link.rule.ids><backlink>$$Uhttp://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=28428335$$DView record in Pascal Francis$$Hfree_for_read</backlink><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/24470482$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Lamberts, Morten</creatorcontrib><creatorcontrib>Gislason, Gunnar H</creatorcontrib><creatorcontrib>Lip, Gregory Y.H</creatorcontrib><creatorcontrib>Lassen, Jens Flensted</creatorcontrib><creatorcontrib>Olesen, Jonas Bjerring</creatorcontrib><creatorcontrib>Mikkelsen, Anders P</creatorcontrib><creatorcontrib>Sørensen, Rikke</creatorcontrib><creatorcontrib>Køber, Lars</creatorcontrib><creatorcontrib>Torp-Pedersen, Christian</creatorcontrib><creatorcontrib>Hansen, Morten Lock</creatorcontrib><title>Antiplatelet Therapy for Stable Coronary Artery Disease in Atrial Fibrillation Patients Taking an Oral Anticoagulant: A Nationwide Cohort Study</title><title>Circulation (New York, N.Y.)</title><addtitle>Circulation</addtitle><description>BACKGROUND—The optimal long-term antithrombotic treatment of patients with coexisting atrial fibrillation and stable coronary artery disease is unresolved, and commonly, a single antiplatelet agent is added to oral anticoagulation. We investigated the effectiveness and safety of adding antiplatelet therapy to vitamin K antagonist (VKA) in atrial fibrillation patents with stable coronary artery disease.
METHODS AND RESULTS—Atrial fibrillation patients with stable coronary artery disease (defined as 12 months from an acute coronary event) between 2002 and 2011 were identified. The subsequent risk of cardiovascular events and serious bleeding events (those that required hospitalization) was examined with adjusted Cox regression models according to ongoing antithrombotic therapy. A total of 8700 patients were included (mean age, 74.2 years; 38% women). During a mean follow-up of 3.3 years, crude incidence rates were 7.2, 3.8, and 4.0 events per 100 person-years for myocardial infarction/coronary death, thromboembolism, and serious bleeding, respectively. Relative to VKA monotherapy, the risk of myocardial infarction/coronary death was similar for VKA plus aspirin (hazard ratio, 1.12 [95% confidence interval, 0.94–1.34]) and VKA plus clopidogrel (hazard ratio, 1.53 [95% confidence interval, 0.93–2.52]). The risk of thromboembolism was comparable in all regimens that included VKA, whereas the risk of bleeding increased when aspirin (hazard ratio, 1.50 [95% confidence interval, 1.23–1.82]) or clopidogrel (hazard ratio, 1.84 [95% confidence interval, 1.11–3.06]) was added to VKA.
CONCLUSIONS—In atrial fibrillation patients with stable coronary artery disease, the addition of antiplatelet therapy to VKA therapy is not associated with a reduction in risk of recurrent coronary events or thromboembolism, whereas risk of bleeding is increased significantly. The common practice of adding antiplatelet therapy to oral VKA anticoagulation in patients with atrial fibrillation and stable coronary artery disease warrants reassessment.</description><subject>Aged</subject><subject>Aged, 80 and over</subject><subject>Anticoagulants - administration & dosage</subject><subject>Anticoagulants - adverse effects</subject><subject>Aspirin - administration & dosage</subject><subject>Aspirin - adverse effects</subject><subject>Atrial Fibrillation - drug therapy</subject><subject>Atrial Fibrillation - mortality</subject><subject>Biological and medical sciences</subject><subject>Blood and lymphatic vessels</subject><subject>Cardiac dysrhythmias</subject><subject>Cardiology. Vascular system</subject><subject>Cohort Studies</subject><subject>Comorbidity</subject><subject>Coronary Artery Disease - drug therapy</subject><subject>Coronary Artery Disease - mortality</subject><subject>Coronary heart disease</subject><subject>Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous</subject><subject>Drug Therapy, Combination</subject><subject>Female</subject><subject>Heart</subject><subject>Hemorrhage - mortality</subject><subject>Humans</subject><subject>Incidence</subject><subject>Male</subject><subject>Medical sciences</subject><subject>Middle Aged</subject><subject>Myocardial Infarction - mortality</subject><subject>Neurology</subject><subject>Phenprocoumon - administration & dosage</subject><subject>Phenprocoumon - adverse effects</subject><subject>Platelet Aggregation Inhibitors - administration & dosage</subject><subject>Platelet Aggregation Inhibitors - adverse effects</subject><subject>Risk Factors</subject><subject>Stroke - mortality</subject><subject>Ticlopidine - administration & dosage</subject><subject>Ticlopidine - adverse effects</subject><subject>Ticlopidine - analogs & derivatives</subject><subject>Vascular diseases and vascular malformations of the nervous system</subject><subject>Vitamin K - antagonists & inhibitors</subject><subject>Warfarin - administration & dosage</subject><subject>Warfarin - adverse effects</subject><issn>0009-7322</issn><issn>1524-4539</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2014</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNqNkd1uEzEQhS0EoqHwCshcIHGzZf23P0hcrBZKI0UNgvR65fXONqaOHWyvojwFr4zTpFS94-rIo2_mzPgg9I7kF4QU5GM7_9HeLJrVfHndXDWpxi7ynFeMP0MzIijPuGD1czTL87zOSkbpGXoVwq_0LFgpXqIzynmZGugM_Wls1FsjIxiIeLUGL7d7PDqPf0bZG8Ct885Kv8eNj5Dkiw4gA2BtcRO9lgZf6t5rk0ZoZ_H3JGBjwCt5p-0tlhYvfYIONsrJ28lIGz_hBl_f8zs9HCzWzsdkOA371-jFKE2ANyc9RzeXX1ftVbZYfpu3zSJTjAueQc0kUFZxKYtqFCOMZTqNlLwciCK94rQvRgWQuKrM64r2QvCCCsIKJXk_sHP04Th3693vCULsNjooSGdYcFPoiCBFSVnN8oTWR1R5F4KHsdt6vUlf0pG8O-TRPc0j1Vh3zCP1vj3ZTP0Ghn-dDwEk4P0JkEFJM3pplQ6PXMVpxZhI3Ocjt3Mm5RDuzLQD361Bmrj-j0X-Aipbqfo</recordid><startdate>20140415</startdate><enddate>20140415</enddate><creator>Lamberts, Morten</creator><creator>Gislason, Gunnar H</creator><creator>Lip, Gregory Y.H</creator><creator>Lassen, Jens Flensted</creator><creator>Olesen, Jonas Bjerring</creator><creator>Mikkelsen, Anders P</creator><creator>Sørensen, Rikke</creator><creator>Køber, Lars</creator><creator>Torp-Pedersen, Christian</creator><creator>Hansen, Morten Lock</creator><general>by the American College of Cardiology Foundation and the American Heart Association, Inc</general><general>Lippincott Williams & Wilkins</general><scope>IQODW</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20140415</creationdate><title>Antiplatelet Therapy for Stable Coronary Artery Disease in Atrial Fibrillation Patients Taking an Oral Anticoagulant: A Nationwide Cohort Study</title><author>Lamberts, Morten ; Gislason, Gunnar H ; Lip, Gregory Y.H ; Lassen, Jens Flensted ; Olesen, Jonas Bjerring ; Mikkelsen, Anders P ; Sørensen, Rikke ; Køber, Lars ; Torp-Pedersen, Christian ; Hansen, Morten Lock</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3454-e93ae2384aa68f5fef76371747d1c1bc42b6fceee93870982b554625136ca4bd3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2014</creationdate><topic>Aged</topic><topic>Aged, 80 and over</topic><topic>Anticoagulants - administration & dosage</topic><topic>Anticoagulants - adverse effects</topic><topic>Aspirin - administration & dosage</topic><topic>Aspirin - adverse effects</topic><topic>Atrial Fibrillation - drug therapy</topic><topic>Atrial Fibrillation - mortality</topic><topic>Biological and medical sciences</topic><topic>Blood and lymphatic vessels</topic><topic>Cardiac dysrhythmias</topic><topic>Cardiology. Vascular system</topic><topic>Cohort Studies</topic><topic>Comorbidity</topic><topic>Coronary Artery Disease - drug therapy</topic><topic>Coronary Artery Disease - mortality</topic><topic>Coronary heart disease</topic><topic>Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous</topic><topic>Drug Therapy, Combination</topic><topic>Female</topic><topic>Heart</topic><topic>Hemorrhage - mortality</topic><topic>Humans</topic><topic>Incidence</topic><topic>Male</topic><topic>Medical sciences</topic><topic>Middle Aged</topic><topic>Myocardial Infarction - mortality</topic><topic>Neurology</topic><topic>Phenprocoumon - administration & dosage</topic><topic>Phenprocoumon - adverse effects</topic><topic>Platelet Aggregation Inhibitors - administration & dosage</topic><topic>Platelet Aggregation Inhibitors - adverse effects</topic><topic>Risk Factors</topic><topic>Stroke - mortality</topic><topic>Ticlopidine - administration & dosage</topic><topic>Ticlopidine - adverse effects</topic><topic>Ticlopidine - analogs & derivatives</topic><topic>Vascular diseases and vascular malformations of the nervous system</topic><topic>Vitamin K - antagonists & inhibitors</topic><topic>Warfarin - administration & dosage</topic><topic>Warfarin - adverse effects</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Lamberts, Morten</creatorcontrib><creatorcontrib>Gislason, Gunnar H</creatorcontrib><creatorcontrib>Lip, Gregory Y.H</creatorcontrib><creatorcontrib>Lassen, Jens Flensted</creatorcontrib><creatorcontrib>Olesen, Jonas Bjerring</creatorcontrib><creatorcontrib>Mikkelsen, Anders P</creatorcontrib><creatorcontrib>Sørensen, Rikke</creatorcontrib><creatorcontrib>Køber, Lars</creatorcontrib><creatorcontrib>Torp-Pedersen, Christian</creatorcontrib><creatorcontrib>Hansen, Morten Lock</creatorcontrib><collection>Pascal-Francis</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Circulation (New York, N.Y.)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Lamberts, Morten</au><au>Gislason, Gunnar H</au><au>Lip, Gregory Y.H</au><au>Lassen, Jens Flensted</au><au>Olesen, Jonas Bjerring</au><au>Mikkelsen, Anders P</au><au>Sørensen, Rikke</au><au>Køber, Lars</au><au>Torp-Pedersen, Christian</au><au>Hansen, Morten Lock</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Antiplatelet Therapy for Stable Coronary Artery Disease in Atrial Fibrillation Patients Taking an Oral Anticoagulant: A Nationwide Cohort Study</atitle><jtitle>Circulation (New York, N.Y.)</jtitle><addtitle>Circulation</addtitle><date>2014-04-15</date><risdate>2014</risdate><volume>129</volume><issue>15</issue><spage>1577</spage><epage>1585</epage><pages>1577-1585</pages><issn>0009-7322</issn><eissn>1524-4539</eissn><coden>CIRCAZ</coden><abstract>BACKGROUND—The optimal long-term antithrombotic treatment of patients with coexisting atrial fibrillation and stable coronary artery disease is unresolved, and commonly, a single antiplatelet agent is added to oral anticoagulation. We investigated the effectiveness and safety of adding antiplatelet therapy to vitamin K antagonist (VKA) in atrial fibrillation patents with stable coronary artery disease.
METHODS AND RESULTS—Atrial fibrillation patients with stable coronary artery disease (defined as 12 months from an acute coronary event) between 2002 and 2011 were identified. The subsequent risk of cardiovascular events and serious bleeding events (those that required hospitalization) was examined with adjusted Cox regression models according to ongoing antithrombotic therapy. A total of 8700 patients were included (mean age, 74.2 years; 38% women). During a mean follow-up of 3.3 years, crude incidence rates were 7.2, 3.8, and 4.0 events per 100 person-years for myocardial infarction/coronary death, thromboembolism, and serious bleeding, respectively. Relative to VKA monotherapy, the risk of myocardial infarction/coronary death was similar for VKA plus aspirin (hazard ratio, 1.12 [95% confidence interval, 0.94–1.34]) and VKA plus clopidogrel (hazard ratio, 1.53 [95% confidence interval, 0.93–2.52]). The risk of thromboembolism was comparable in all regimens that included VKA, whereas the risk of bleeding increased when aspirin (hazard ratio, 1.50 [95% confidence interval, 1.23–1.82]) or clopidogrel (hazard ratio, 1.84 [95% confidence interval, 1.11–3.06]) was added to VKA.
CONCLUSIONS—In atrial fibrillation patients with stable coronary artery disease, the addition of antiplatelet therapy to VKA therapy is not associated with a reduction in risk of recurrent coronary events or thromboembolism, whereas risk of bleeding is increased significantly. The common practice of adding antiplatelet therapy to oral VKA anticoagulation in patients with atrial fibrillation and stable coronary artery disease warrants reassessment.</abstract><cop>Hagerstown, MD</cop><pub>by the American College of Cardiology Foundation and the American Heart Association, Inc</pub><pmid>24470482</pmid><doi>10.1161/CIRCULATIONAHA.113.004834</doi><tpages>9</tpages></addata></record> |
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| subjects | Aged Aged, 80 and over Anticoagulants - administration & dosage Anticoagulants - adverse effects Aspirin - administration & dosage Aspirin - adverse effects Atrial Fibrillation - drug therapy Atrial Fibrillation - mortality Biological and medical sciences Blood and lymphatic vessels Cardiac dysrhythmias Cardiology. Vascular system Cohort Studies Comorbidity Coronary Artery Disease - drug therapy Coronary Artery Disease - mortality Coronary heart disease Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous Drug Therapy, Combination Female Heart Hemorrhage - mortality Humans Incidence Male Medical sciences Middle Aged Myocardial Infarction - mortality Neurology Phenprocoumon - administration & dosage Phenprocoumon - adverse effects Platelet Aggregation Inhibitors - administration & dosage Platelet Aggregation Inhibitors - adverse effects Risk Factors Stroke - mortality Ticlopidine - administration & dosage Ticlopidine - adverse effects Ticlopidine - analogs & derivatives Vascular diseases and vascular malformations of the nervous system Vitamin K - antagonists & inhibitors Warfarin - administration & dosage Warfarin - adverse effects |
| title | Antiplatelet Therapy for Stable Coronary Artery Disease in Atrial Fibrillation Patients Taking an Oral Anticoagulant: A Nationwide Cohort Study |
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