Utilization of Triple Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Abstract

Abstract Background: Triple antithrombotic therapy (TAT), a combination of an oral anticoagulant and dual antiplatelet agents (DAPT), is a key treatment for prevention of ischemic events in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). However, TAT is not extensively used because of the risk of bleeding. This study aimed to determine the utilization and influencing factors of TAT using real-world data in the non-vitamin K antagonist oral anticoagulants (NOACs) era. Methods: We analyzed National Inpatient Sample data compiled by the Health Insurance Review & Assessment Service (HIRA-NIS) from 2011 to 2020. Patients with AF who underwent PCI with stent implantation and with an increased stroke risk, were selected as candidates for TAT therapy. Demographic and clinical factors associated with TAT use were investigated using the chi-squared test and the student's t-test, and influencing factors were identified using multiple logistic regression. Results: The TAT utilization rate steadily increased from 30.3% in 2011 to 65.4% in 2020 (Cochran-Armitage trend test: p < 0.001) with an average of 45.9%. Positive influencing factors for TAT use were identified as congestive heart failure, history of previous stroke/transient ischemic attack/thromboembolism, valvular heart disease, and year. Negative influencing factors included insurance type (medical aid or Patriots & Veterans Insurance), type of medical institution (general hospitals or primary medical institutions), and comorbidities such as renal disease, liver disease, and history of the previous hemorrhage. Conclusions: In patients with AF with an increased stroke risk, TAT utilization after PCI increased progressively from 2011 to 2020, reaching 65.4% by 2020. However, in 2020, 29.4% of patients were still prescribed DAPT, suggesting that many AF patients undergoing PCI did not receive adequate antithrombotic therapy even in the NOACs era. This trend was more pronounced in patients at high risk of bleeding.