The Latest and Greatest in Anticoagulation — Still Not a Good Idea After ACS

The newer oral anticoagulants are associated with increased rates of major bleeding that offset their antithrombotic benefit.

The burgeoning use of new oral anticoagulants (e.g., dabigatran, rivaroxaban, apixaban) has rekindled interest in whether these agents, combined with standard antiplatelet therapy, could reduce thrombotic events after acute coronary syndromes (ACS). To synthesize the current evidence base, researchers performed a meta-analysis of seven trials in which 31,286 ACS patients were randomized to placebo or a new oral anticoagulant, either an anti-Xa or direct thrombin inhibitor. All patients also received antiplatelet therapy, and most received dual antiplatelet therapy with aspirin and a thienopyridine.

Although the risk for major ischemic events was significantly lower in recipients of new-generation oral anticoagulants than in placebo recipients, the risk for major bleeding events was significantly higher. No significant difference was found between the groups in either net clinical benefit (incorporating both the composite of ischemic events and major bleeding) or mortality.

• Thrombolysis in myocardial infarction (TIMI) major bleeding events — odds ratio, 3.03; 95% CI, 2.20–4.16
• Overall mortality — OR, 0.90; 95% CI, 0.76–1.06
• Composite ischemic events — OR, 0.86; 95% CI, 0.79–0.94
• Stent thrombosis (definite or probable) — OR, 0.73; 95% CI, 0.54–0.98

CITATION(S):

Komócsi A et al. Use of new-generation oral anticoagulant agents in patients receiving antiplatelet therapy after an acute coronary syndrome: Systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2012 Sep 24; [e-pub ahead of print].

Hernandez AV. No place for novel oral anticoagulants in current treatment of acute coronary syndromes. Arch Intern Med 2012 Sep 24; [e-pub ahead of print].