Coronary interventions

Antithrombotic strategy variability in atrial fibrillation and obstructive coronary disease revascularised with percutaneous coronary intervention: primary results from the AVIATOR 2 international registry

EuroIntervention 2022;18:e656-e665. DOI: 10.4244/EIJ-D-21-01044

Jaya Chandrasekhar
Jaya Chandrasekhar1,2, MBBS, MS, PhD; Usman Baber3, MD, MS; Samantha Sartori1, PhD; Ridhima Goel1,4, MD; Johny Nicolas1, MD; Birgit Vogel1, MD; Clayton Snyder1, MPH; Annapoorna Kini1, MD; Carlo Briguori5, MD, PhD; Bernhard Witzenbichler6, MD; Ioannis Iakovou7, MD; Gennaro Sardella8, MD; Kevin Marzo9, MD; Anthony DeFranco10, MD; Thomas Stuckey11, MD; Alaide Chieffo12, MD; Antonio Colombo13, MD; Richard Shlofmitz14, MD; Davide Capodanno15, MD, PhD; George Dangas1, MD, PhD; Stuart Pocock16, PhD; Roxana Mehran1, MD
1. Icahn School of Medicine at Mount Sinai, New York, NY, USA; 2. Box Hill Hospital, Eastern Health Clinical School and Monash University, Melbourne, Australia; 3. University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; 4. State University of New York, SUNY Downstate Medical Center, Brooklyn, NY, USA; 5. Mediterranea Cardiocentro, Naples, Italy; 6. Helios Amper-Klinikum, Dachau, Germany; 7. Onassis Cardiac Surgery Center, Athens, Greece; 8. Policlinico Umberto I, Rome, Italy; 9. NYU Langone Hospital-Long Island, Mineola, NY, USA; 10. Aurora Health Care, Milwaukee, WI, USA; 11. Cone Health Lebauer HealthCare, Greensboro, NC, USA; 12. San Raffaele Hospital, Milan, Italy; 13. Department of Biomedical Sciences, Humanitas University, Milan, Italy and IRCCS Humanitas Research Hospital, Italy; 14. Saint Francis Hospital and Heart Center, New York, NY, USA; 15. Ferrarotto Hospital, University of Catania, Catania, Italy; 16. London School of Hygiene and Tropical Medicine, London, United Kingdom

Background: Managing percutaneous coronary intervention (PCI) patients with atrial fibrillation (AF) presents challenges given that there are several potential antithrombotic therapy (ATT) strategies.

Aims: We examined ATT patterns, agreement between subjective physician ratings and validated risk scores, physician-patient perceptions influencing ATT and 1-year outcomes.

Methods: The AVIATOR 2 prospective registry enrolled 514 non-valvular AF-PCI patients from 11 sites. Treating physicians selected ATT and completed smartphone surveys rating stroke and bleeding risks, compared against CHA2DS2-VASc and HAS-BLED scores. Patients completed surveys regarding treatment understanding. Primary outcomes were 1-year major adverse cardiac or cerebrovascular events (MACCE: composite of death, myocardial infarction, definite/probable stent thrombosis, stroke, target lesion revascularisation) and actionable bleeding (Bleeding Academic Research Consortium 2, 3 or 5).

Results: The mean patient age was 73.2±9.0 years, including 25.8% females. Triple therapy (TT: 1 anticoagulant and 2 antiplatelet agents) was prescribed in 66.5%, dual antiplatelet therapy (DAPT) in 20.7% and dual therapy (1 anticoagulant+1 antiplatelet agent) in 12.8% of patients. Physician ratings and validated risk scores showed poor agreement (stroke: kappa=0.03; bleeding: kappa=0.07). Physicians rated bleeding-related safety (93.8%) as the main factor affecting ATT choice. Patients worried about stroke over bleeding (50.6% vs 14.8%). No group differences by ATT strategy were observed in 1-year MACCE (TT 14.1% vs dual therapy 12.7% vs DAPT 18.5%; p=0.25), or actionable bleeding (14.7% vs 7.9% vs 15.1%, respectively; p=0.89).

Conclusions: The AVIATOR 2 study is the first digital health study examining physician-patient perspectives on ATT choices after AF-PCI. TT was the most common strategy without differences in 1-year outcomes in ATT strategy. Physicians rated safety first when prescribing ATT; patients feared stroke over bleeding. NCT02362659

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