Assessing the Safety of DOAC Plus Antiplatelet Therapy After Carotid Artery Stenting in Nonvalvular AF

Administration of a direct oral anticoagulant (DOAC) in combination with an antiplatelet agent may reduce the risk for hemorrhagic and embolic events in patients with nonvalvular atrial fibrillation following carotid artery stenting, according to study results published in Journal of Stroke & Cerebrovascular Disease.

Dual antiplatelet therapy is used to prevent thromboembolism following carotid artery stenting but may be associated with increased risk for hemorrhagic events in patients who are also treated with anticoagulants. Therefore, investigators aimed to identify the optimal anti-thromboembolic treatment following carotid artery stenting for patients with nonvalvular atrial fibrillation. 

A total of 31 patients (93.5% men; mean age, 77.0 years) with nonvalvular atrial fibrillation and treated with anticoagulants prior to stenting were included in this study. Of those patients, 17 received a vitamin K antagonist and 14 received a DOAC. All patients received aspirin (100 mg/day) and clopidogrel (75 mg/day) for ≥5 days before stenting. After stenting, aspirin (n=6) or clopidogrel (n=8) was discontinued in the DOAC group

Patients in the DOAC group received dabigatran (n=9), rivaroxaban (n=2), apixaban (n=2), or edoxaban (n=1). Patients received either a standard dose (n=3) or low dose (n=11) of their respective drug.

Outcomes of interest included hemorrhagic or thromboembolic events that occurred within 6 months of stenting. Angiographic imaging was conducted 6 to 12 months after the procedure or when in-stent restenosis was suspected.

Carotid artery stenting was successful in all patients, as determined on angiography, with no periprocedural neurologic or cardiologic events. No patients experienced ischemic stroke post-procedure. Complications were observed in 2 patients in the vitamin K antagonist group, including 1 instance of silent subarachnoid hemorrhage and 1 instance of necrosis of the small intestine due to superior mesenteric artery occlusion at 6 months. No patients in the DOAC group experienced any hemorrhagic or thromboembolic events after stenting.

The researchers noted that the small sample size of the study prevented the identification of any statistically significant differences with respect to the safety and efficacy of treatment.

“Our findings suggest that the administration of DOAC plus [single antiplatelet therapy] rather than [vitamin K antagonist] plus conventional [dual antiplatelet therapy] tends to prevent hemorrhagic and embolic events in patients with [nonvalvular atrial fibrillation] who underwent [carotid artery stenting],” the study authors concluded. “The effects of the prolonged delivery of multiple antithrombotic agents and the residual effects of anticoagulants administered after neurointervention must be carefully considered especially in patients at high risk for hemorrhagic and embolic events.”

Reference

Nii K, Takemura Y, Inoue R, Morinaga Y, Mitsutake T, Higashi T. Safety of direct oral anticoagulant – and antiplatelet therapy in patients with atrial fibrillation treated by carotid artery stenting [published online May 10, 2020]. J Stroke Cerebrovasc Dis. doi:10.1016/j.jstrokecerebrovasdis.2020.104899