Direct oral anticoagulant plus antiplatelet therapy: prescribing practices and bleeding outcomes
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Concurrent antiplatelet therapy (APT) is common during warfarin therapy but is less well-documented during direct oral anticoagulant (DOAC) therapy. Combined anticoagulant and APT use has been associated with increased bleeding risk without providing additional protection against thrombosis. This study aimed to describe single-center prescribing rates of DOAC + APT as well as compare bleeding rates between DOAC monotherapy and DOAC + APT cohorts. Patients receiving DOAC therapy were evaluated for APT use at the time of hospital discharge. Patients were categorized into DOAC monotherapy and DOAC + APT cohorts. Primary outcomes included DOAC + APT prescribing rate as well as rates of major bleeding and clinically relevant non-major bleeding (CRNMB) within six months after hospital discharge. Secondary outcomes included rates of thromboembolism and all-cause mortality. Of 407 patients receiving DOAC therapy, 78 (19.2%) also received APT at hospital discharge. Common indications for APT included secondary cardiovascular event prevention (57.7%) and primary cardiovascular event prevention (29.5%). The indication for APT could not be determined in 12.8% of patients. The major bleeding rate was 1.3% for DOAC + APT and 1.2% for DOAC monotherapy (p = 0.95). The CRNMB rate was 10.2% for DOAC + APT and 6.4% for DOAC monotherapy (p = 0.23). Thromboembolism and mortality were infrequent in both cohorts. DOAC + APT was documented in approximately 1 of 5 patients. Adding APT to DOAC therapy did not significantly increase the major bleeding or CRNMB rates compared to DOAC monotherapy but the sample size limits drawing conclusions about the safety of these regimens. Targeting primary prevention or unclear indications for APT could be a focus of future interventions.
KeywordsDirect oral anticoagulant Antiplatelet Aspirin Bleeding
The authors would like to acknowledge Stacy A. Johnson, MD for assistance with data retrieval.
This study received no external funding.
Compliance with ethical standards
Conflict of interest
Sara R. Vazquez declares that she is an editorial consult for UpToDate® and a member of the Anticoagulation Forum Board of Directors. Daniel M. Witt declares that he is a member of the Anticoagulation Forum Advisory Council and has received grant funding unrelated to this study from Roche Diagnostics Corporation (RD003737). The other authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the University of Utah Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Due to the retrospective chart review design of the study, the University of Utah Institutional Review Board waived the requirement for informed consent.
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