2018, Volume 25, Supplement 1: Anticoagulation in atrial fibrillation: focus on PIONEER AF-PCI and its implications

Patients with atrial fibrillation are at an increased risk for ischaemic stroke and require long-term prophylaxis with an anticoagulant. Ablation and direct current cardioversion are commonly performed in patients with atrial fibrillation. These procedures additionally predispose patients to thrombotic events and peri-procedural anticoagulation is also indicated....

The PIONEER AF-PCI trial was an open-label, randomised, controlled, multi-centre trial that evaluated the safety of two different regimens of rivaroxaban compared with vitamin K antagonist (VKA) in patients with non-valvular atrial fibrillation (NVAF) who underwent percutaneous coronary intervention (PCI) with stent placement. PIONEER AF-PCI was a safety study. The primary safety end point was the occurrence of clinically significant bleeding. This end point was a composite of Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding or bleeding requiring medical attention (BRMA) and was evaluated throughout the 12-month treatment period. Low-dose (15 mg once daily) and very-low-dose (2.5 mg twice daily) rivaroxaban-based strategies were associated with a 39% relative risk reduction in clinically significant bleeding when compared with VKA triple therapy through 12 months (combined-rivaroxaban vs. VKA: 17.4% vs. 26.7%, p<0.001). The individual rivaroxaban regimens also demonstrated a superior safety profile when compared with the traditional VKA regimen (2.5 mg vs. VKA: 18.0% vs. 26.7%, p<0.001; and 15 mg vs. VKA: 16.8% vs. 26.7%, p<0.001). Similar rates of the exploratory efficacy end point (cardiovascular death, MI, stroke, and stent thrombosis) were observed; but the study was not powered for statistical significance on efficacy. The clinical implications of the trial are discussed....

Our ageing population is resulting in increasing rates of coronary artery disease and atrial fibrillation (AF), which require intervention. Anticoagulation in patients with non-valvular AF undergoing percutaneous coronary intervention (PCI) is a growing challenge. As a consequence, we are now in an era of investigating optimal regimens to minimise bleeding risk, while not compromising the efficacy of stroke prevention or coronary secondary prevention in patients with these comorbidities. This paper looks at current treatment guidelines and developments with the PIONEER AF-PCI study, and their implications for UK practice....

The procedural and post-procedure risk of stroke associated with catheter ablation of atrial fibrillation (AF), even in patients with low CHA2DS2-VASc scores, highlight the need for effective anticoagulation in this patient population. Warfarin has been the mainstay of anticoagulant therapy, although its use has been impacted by the advent of non-vitamin K antagonist oral anticoagulants (NOACs). Despite some initial concerns on bleeding risk and reversibility with the NOACs, studies have shown a reduced stroke rate and comparable bleeding events when NOACs are compared with warfarin. We look at approaches to their use in the cardiac ablation setting....

Direct current cardioversion (DCCV) is a frequently used and effective strategy for the restoration of sinus rhythm in patients with atrial fibrillation (AF). Anticoagulation for stroke prevention in AF has historically been with a vitamin K antagonist (VKA), such as warfarin – both for long-term thromboprophylaxis and, specifically, for patients undergoing DCCV. The strategy has limitations, however, and the use of the non-VKA oral anticoagulants (NOACs) is increasingly common in patients with non-valvular AF who are considered for DCCV. We review the evidence of safety and efficacy from recently reported trials....