Patient Characteristics Associated With the Choice of Triple Antithrombotic Therapy in Acute Coronary Syndromes
Am J Cardiol 2009; 104: 1171–1178 View citation
Evidence regarding the use of dual antiplatelet therapy and oral anticoagulation (i.e., triple therapy) in acute coronary syndromes (ACS) is limited. We evaluated the characteristics associated with the choice of triple therapy in ACS. Using the Get With The Guidelines (GWTG) Coronary Artery Disease national registry, we studied patients with ACS at 361 sites in the United States from 2004 to 2007. Both univariate analysis and multivariate logistic regression analysis were used to assess the factors associated using triple therapy on discharge. The Generalized Estimating Equation method was used to account for within-hospital clustering in modeling. A total of 86,304 patients presented with ACS during the study period. At discharge, 3,933 patients (4.6%) were prescribed triple therapy, 60,716 patients (70.4%) received dual antiplatelet therapy, 2,348 patients (2.7%) received single antiplatelet therapy plus oral anticoagulation, 19,065 patients (22.1%) received antiplatelet monotherapy, and 242 patients (0.3%) received oral anticoagulation alone. Patients with a history of atrial fibrillation (odds ratio 7.01, 95% confidence interval 6.06 to 8.12; p <0.001), documented new-onset atrial fibrillation (odds ratio 3.76, 95% confidence interval 2.87 to 4.93; p <0.001), or history of atrial flutter (odds ratio 3.38, 95% confidence interval 2.15 to 5.32; p <0.001) were more frequently discharged with triple therapy. In conclusion, for patients with ACS, atrial fibrillation and atrial flutter were most strongly associated with the use of triple therapy; however, this therapy was used less often than dual or single antiplatelet therapy. a Department of Internal Medicine/Medicine Institute, Cleveland Clinic, Cleveland, Ohio b TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts c University of California, Los Angeles, Medical Center, Los Angeles, California d Duke Clinical Research Institute, Durham, North Carolina e Department of Emergency Medicine, Cleveland Clinic, Cleveland, Ohio f Veterans Affairs Boston Healthcare System and Brigham and Women's Hospital, Boston, Massachusetts Corresponding author: Tel: 1-857-203-6840/6841; fax: 1-857-203-5550 This study was supported by a grant from the Council on Clinical Cardiology of the American Heart Association, Dallas, Texas; the Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program is funded in part by the Merck Schering-Plough partnership, North Wales, Pennsylvania. Data collection and management were performed by Outcome Sciences, Cambridge, Massachusetts. The analysis of registry data were performed at Duke Clinical Research Institute, Durham, North Carolina, which also receives funding from the American Heart Association. The sponsor was not involved in the management, analysis, or interpretation of data or the preparation of the manuscript. Dr. Cannon has received research grants/support from Accumetrics (San Diego, California), AstraZeneca (London, UK), Bristol-Myers Squibb/Sanofi Partnership (Bridgewater, New Jersey), GlaxoSmithKline (Philadelphia, Pennsylvania), Intekrin Therapeutics (Los Altos, California), Merck (Whitehouse Station, New Jersey), Merck/Schering Plough Partnership, Novartis (East Hanover, New Jersey), and Takeda (Osaka, Japan). He serves as a clinical advisor and equity partner in Automedics Medical Systems (San Diego, California). He also serves as the chair of the Get With The Guidelines Steering Science Subcommittee; Dr. Fonarow has received research funding from GlaxoSmithKline and Medtronic (Minneapolis, Minnesota), served as consultant, and/or received honorarium from Bristol Myers Squibb (Princeton, New Jersey), GlaxoSmithKline, Medtronic, Merck, Pfizer (New York, New York), Sanofi-Aventis (Paris, France), and Schering Plough (Kenilworth, New Jersey) and serves as the chair of the Get With The Guidelines Steering Committee of the American Heart Association; Dr. Bhatt has received research grants from Bristol Myers Squibb, Sanofi Aventis, Heartscape (Columbia, Maryland), the Medicines Company (Parsippany, New Jersey), Eisai (Tokyo, Japan), and Ethicon (New Brunswick, New Jersey) and has served as a consultant to Arena (San Diego, California), Astellas (Tokyo, Japan), AstraZeneca, Bayer (Leverkusen, Germany), Bristol Myers Squibb, Cardax (Honolulu, Hawaii), Centocor (Horsham, Pennsylvania), Cogentus (Palo Alto, California), Daiichi Sankyo (Tokyo, Japan), Eisai, Eli Lilly (Indianapolis, Indiana), GlaxoSmithKline, Johnson & Johnson (New Brunswick, New Jersey), McNeil (New Brunswick, New Jersey), Medtronic, Millennium (Cambridge Massachusetts), Molecular Insights (Cambridge, Massachusetts), Otsuka (Rockville, Maryland), Paringenix (Tucson, Arizona), PDL (Redwood City, California), Philips (Amsterdam, Netherlands), Portola (San Francisco, California), Sanofi Aventis, Schering Plough, Takeda, the Medicines Company, and Vertex (Cambridge, Massachusetts); and Dr. Peacock has received research funding from Abbott (Abbott Park, Illinois), Biosite (San Diego, California), Brahms (Annapolis, Maryland), Cothera (San Mateo, California) Heartscape, Inovise (Beaverton, Oregon), Inverness (Waltham, Massachusetts), EKR (Bedminster, New Jersey), the Medicines Company, has served on the scientific advisory board for Abbott, Beckman-Coulter (Fullerton, California), Biosite, Heartscape, Inovise, Ortho-Clinical Diagnostics (Rochester, New York), and the Medicines Company, and has been on the speaker's bureau of Abbott and Biosite.
