Aspirin, Warfarin, or the Combination for Secondary Prevention of Coronary Events in Patients With Acute Coronary Syndromes and Prior Coronary ...
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Aspirin, Warfarin, or the Combination for Secondary Prevention of Coronary Events in Patients With Acute Coronary Syndromes and Prior Coronary Artery Bypass Surgery Thao Huynh, MD; Pierre Théroux, MD; Peter Bogaty, MD; James Nasmith, MD; Susan Solymoss, MD Background—Patients with a non–ST-elevation acute coronary syndrome and prior CABG are at high risk of a recurrent ischemic event despite aspirin therapy. This trial investigated the potential benefit of secondary prevention with warfarin. Methods and Results—In a double-blind randomized trial, 135 patients with unstable angina or non–ST-segment elevation myocardial infarction, with prior CABG, and who were poor candidates for a revascularization procedure received therapy with aspirin and placebo⫹warfarin, warfarin and placebo⫹aspirin, or aspirin and warfarin for 12 months. Warfarin was titrated to an international normalized ratio of 2.0 to 2.5. The primary end point (death or myocardial infarction or unstable angina requiring hospitalization 1 year after randomization) occurred in 14.6% of the patients in the warfarin-alone group, in 11.5% of patients in the aspirin-alone group, and in 11.3% of patients randomized to the combination therapy (P⫽0.76). Subgroup analyses by risk features provided no indications that warfarin alone or in combination with aspirin could be of benefit over aspirin alone. Bleeding was more frequent in the 2 groups of patients administered warfarin. Conclusions—Moderate-intensity oral anticoagulation alone or combined with low-dose aspirin does not appear to be superior to low-dose aspirin in the prevention of recurrent ischemic events in patients with non–ST-elevation acute coronary syndromes and previous CABG. (Circulation. 2001;103:3069-3074.) Key Words: warfarin sodium 䡲 anticoagulants 䡲 aspirin 䡲 coronary disease C ardiac events are frequent in patients with previous CABG and are associated with an impaired prognosis.1– 4 Aspirin prevents graft closure during the first year after unstable angina or non–ST-elevation myocardial infarction and prior CABG were considered for the study. The diagnosis of unstable angina was based on an accelerating pattern of chest pain occurring at rest or with minimal exertion or of a prolonged chest pain and surgery,5–12 but its long-term benefit in this specific setting normal serum levels of creatine kinase (CK). A non–ST-segment has not been documented. Warfarin had been evaluated in elevation myocardial infarction was diagnosed when serum CK-MB unstable angina,13 but no studies have addressed the specific increased above the upper normal limit of the site in the absence of population of patients with unstable coronary syndromes new Q waves on the ECG. Patients who had coronary angioplasty or without ST elevation developing late after CABG. Because of repeat CABG during the index hospitalization were excluded; therefore, the study population was limited to patients who were poor the high frequency of flow stasis, thrombi, and fibrin-rich candidates for a revascularization procedure. Other exclusion criteria thrombi associated with venous graft disease,14 –16 long-term were as follows: contraindication to the use of aspirin or warfarin, a anticoagulation with warfarin may be particularly beneficial treatable cause for angina pectoris, any major concomitant illness, in this situation. We tested the hypothesis that moderate- congestive heart failure class 3 or 4 (New York Heart Association), intensity warfarin (international normalized ratio [INR] 2 to uncontrolled systemic hypertension (blood pressure ⬎180/ 95 mm Hg), recent major trauma, alcohol or drug abuse, females 2.5) either alone or in combination with low-dose aspirin will with child-bearing potential, coronary angioplasty within the last 6 be more effective than aspirin alone for the secondary months, conditions mandating treatment with aspirin (such as previ- prevention of coronary events in patients with previous ous stroke) or with warfarin (such as metallic valve prosthesis), atrial CABG. fibrillation, or intracardiac thrombi. All patients gave informed consent to participate, and the institutional review board at each participating hospital approved the protocol. Methods Selection of Patients Study Protocol The present study was conducted at 4 referral cardiology centers in In a double-blind parallel-group study design, patients were random- Quebec, Canada. All patients who presented with a diagnosis of ized to 1 of 3 parallel study groups: (1) aspirin plus placebo-warfarin, Received October 12, 2000; revision received April 9, 2001; accepted April 9, 2001. From the Montreal General Hospital (T.H., S.S.), the Montreal Heart Institute (P.T.), and Sacré-Coeur Hospital (J.N.), Montreal, Quebec, and the Quebec Heart Institute (P.B.), Quebec, Quebec, Canada. Reprint requests to Pierre Theroux, MD, Montreal Heart Institute, 5000 Belanger East St, Montreal, Quebec, Canada H1T 1C8. E-mail firstname.lastname@example.org © 2001 American Heart Association, Inc. Circulation is available at http://www.circulationaha.org 3069
3070 Circulation June 26, 2001 TABLE 1. Clinical Characteristics of Study Patients Warfarin⫹Placebo Aspirin⫹Placebo Aspirin⫹Warfarin Characteristic (n⫽45) (n⫽46) (n⫽44) P Age (mean⫾SD), y 67⫾12 68⫾11 66⫾12 0.90 Females, % 13.6 17.8 29.3 0.18 Mean LVEF, % 30.9 29.4 29.4 0.99 LVEF ⬍40%, % 53.3 41.3 56.8 0.29 Interval between randomization 8.5 7.2 6.9 0.20 and CABG, y Prior MI, % 62.2 56.5 72.7 0.38 Current smoking, % 31.1 17.8 20.5 0.29 Hypertension, % 37.8 34.8 38.6 0.73 Hyperlipidemia, % 62.2 43.5 68.2 0.11 Diabetes mellitus, % 15.6 17.4 25.0 0.50 CCS class ⬎3, % 13.3 13.0 20.5 0.30 Cardiac catheterization,* % 57.7 65.2 52.2 0.46 MI indicates myocardial infarction. Values are mean percentage unless specified differently. *During index hospitalization. (2) warfarin plus placebo-aspirin, or (3) aspirin plus warfarin. and associated with elevated serum CK-MB levels (above the upper Aspirin was administered as a daily dose of 80 mg in nonenteric normal limit of the site) or with new Q waves. Unstable angina was coated form. Warfarin was given as crystalline warfarin sodium considered as a study end point only when it was severe enough to tablets (Coumadin). Placebo tablets were supplied by Dupont require hospitalization and there was a confirmed diagnosis at Pharma Canada. In-hospital follow-up visits were scheduled at 1, 3, hospital discharge. Atypical chest pain requiring hospitalization was 6, and 12 months of treatment. The study drugs were terminated at not counted as an end point. All events were classified before the 12-month follow-up visit, and aspirin (325 mg daily) was conditions of the blind study were revealed. prescribed to all patients. Patients were reevaluated 1 month after the discontinuation of the study drugs. Statistical Analyses The study was terminated prematurely after enrollment of half the Study Monitoring planned number of patients because of difficulty in recruiting Measurements of INR were performed 3 days and 1 week after study because of the high rate of conventional or investigative procedures drug initiation. Subsequent visits were scheduled depending on INR performed in otherwise qualifying patients. The baseline character- stability. Hemoglobin and hematocrit were monitored at the time of istics of the 3 study groups were compared by 2 and Student tests. INR determination. Unblinded pharmacists or physicians, not other- End-point events were group-classified by the intention-to-treat wise involved in the study and patient care, adjusted warfarin to a target INR of 2.0 to 2.5 by using a predefined algorithm. To maintain principle. Intergroup differences for event rates were compared by the double-blind integrity, patients assigned to aspirin plus placebo- the 2 statistics with the use of 2⫻3 tables. The event rates for the warfarin therapy also had regular blood tests and mock placebo- primary end point of death, myocardial infarction, and documented warfarin adjustments. Major bleeding was defined as a fall in recurrent unstable angina were displayed by the Kaplan-Meier hemoglobin of ⱖ2 g/L or requiring blood product transfusion. Minor survival method and tested for statistical significance by the log-rank bleeding was defined as all other bleeding events reported by the statistic. Events rates were also compared in subgroups with higher patients and/or health care professionals. In the event of clinically risk features identified by univariate and multivariate analyses of the significant bleeding, the study drugs were discontinued, and patients baseline characteristics associated with an impaired prognosis. Sta- were transfused as necessary. Compliance was defined as 100% of tistical significance was defined by a value of P⬍0.05. The SPSS study medication taken (pills were counted by research coordina- Base 10.0 (SPSS Advanced Models 10.0 statistical software) served tors). Study drugs could be temporarily interrupted for major for the statistical analyses. illnesses, elective surgeries, and dental treatment. The study code was broken only when it was essential for optimal patient Results management. The baseline clinical characteristics of patients in the 3 study Other Therapies groups are shown in Table 1. Mean age, left ventricular Concomitant medications could be prescribed at the discretion of the systolic function (left ventricular ejection fraction [LVEF]), attending physicians, but drugs known to interact with warfarin or to and time elapsed after CABG were similar among the increase the bleeding risk (barbiturates, NSAIDs, and salicylates) patients. Although no statistically significant differences were prohibited during the whole study period. All patients received existed between the 3 groups, there were more patients that aspirin at the end of the 12-month study period, when study drugs were discontinued. were female and had prior MI, diabetes, and functional impairment by angina in the group assigned to Study End Points aspirin⫹warfarin and fewer patients with depressed LVEF The primary study end point was a composite end point of any-cause (⬍40%) in the group assigned to aspirin⫹placebo than in the death, myocardial infarction, or unstable angina requiring a new other 2 groups. More than 60% of the patients had prior hospitalization. Other end points were performance of reperfusion procedure (either percutaneous or open chest). Myocardial infarction myocardial infarction. Cardiac catheterization was performed was defined as typical chest pain or discomfort lasting ⱖ30 minutes in 60% of patients during the index hospitalization. The time
Huynh et al Aspirin and Warfarin in ACS With Prior CABG 3071 TABLE 2. Baseline Medical Therapy of Study Patients Warfarin⫹Placebo Aspirin⫹Placebo Warfarin⫹Aspirin Medications (n⫽45) (n⫽46) (n⫽44) P ␤-Blockers, % 57.8 71.7 70.5 0.30 Calcium channel blockers, % 55.6 52.2 54.5 0.95 Nitrates, % 64.4 63.0 75.0 0.95 Lipid-lowering agents, % 42.2 37.0 36.4 0.82 ACE inhibitors, % 35.6 15.3 22.7 0.07 Antiarrhythmic agents, % 6.8 2.2 4.6 0.53 Diuretics, % 26.7 11.0 34.1 0.03 elapsed between the last CABG and occurrence of the index Patients using diuretics at the time of entry into the study had acute coronary event averaged 7.5 years. rates of 15.6%, 6.5%, and 13.6%, respectively, and those Table 2 shows the medical treatment received at the time of using ACE inhibitors had rates of 13.3%, 8.7%, and 9.1%, randomization. Patients in the warfarin⫹placebo group more respectively. often received ACE inhibitors and lipid-lowering drugs and Table 4 shows the distribution of complications among the less often received ␤ -blockers; patients assigned to 3 treatment arms. Minor bleeds were more frequent in aspirin⫹placebo less often received diuretics and ACE inhib- patients receiving warfarin (P⫽0.02), either as single therapy itors; and patients in the combination group more often (8.9%) or in combination (9.8%), than in those receiving only received nitrates. aspirin (1.5%). Major bleeding occurred only in patients Table 3 presents the study end points for the 3 treatment receiving the anticoagulant. Two patients on warfarin⫹ arms, and the Figure presents the cumulative event rates. No placebo and 2 patients on warfarin⫹aspirin required blood statistically significant differences existed between groups in transfusions. In the present study, compared with warfarin the incidence of the primary end point. End points regrouped alone, the addition of 80 mg of aspirin to warfarin treatment or considered individually and secondary end points were all resulted in no excess bleeding. No significant excess in less frequent in the aspirin-alone arm than in the 2 other arms. clinical events occurred in the month after cessation of the A percutaneous procedure during follow-up was also per- study drugs, with all patients administered open-label aspirin formed more frequently in the 2 groups of patients random- (Figure). ized to receive warfarin. The rate of completion of protocol was high among the 3 Baseline characteristics associated with an impaired prog- groups. The reasons for premature cessation of study medi- nosis were as follows: age ⱖ65 years (relative risk [RR] 1.65, cations were diverse; most of the reasons for cessation were P⫽0.19), male sex (RR 2.32, P⫽0.11), diabetes (RR 2.23, medical conditions requiring nonstudy use of warfarin or P⫽0.07), and Canadian Cardiovascular Society (CCS) angina aspirin. Three patients had to stop the study drugs because of class ⱖ3 (RR 1.83, P⫽0.31). Treatment effects in all sub- bleeding. Nonstudy use of warfarin was required in 5 patients groups showed no trends to a benefit with Coumadin alone or on warfarin⫹placebo, 2 patients on aspirin⫹placebo, and 2 in combination with aspirin over aspirin alone. Thus, the patients on aspirin⫹warfarin. Three patients (1 in each event rates in the warfarin-alone, aspirin-alone, and treatment group) were lost to follow-up. warfarin⫹aspirin groups were, respectively, as follows: in patients aged ⬍65 years, 40%, 22.7%, and 19%; in patients Discussion aged ⱖ65 years, 41.7%, 34.8%, and 36.8%; among women, No benefit of warfarin alone or of warfarin⫹aspirin com- 9%, 0%, and 10%; among men, 15.7%, 15.3%, and 13.8%; pared with aspirin alone could be documented for the sec- among diabetics, 13%, 18%, and 30%; among patients with ondary prevention of ischemic events in the present study of LVEF ⬍40%, 11%, 8%, and 12%; and among patients in patients with previous CABG and an acute coronary syn- CCS class 3 or 4 at randomization, 6.3%, 0%, and 9.1%. drome (ACS). The composite end point and the various TABLE 3. End-Point Events According to Treatment Warfarin⫹Placebo Aspirin⫹Placebo Warfarin⫹Aspirin Events (n⫽45) (n⫽46) (n⫽44) P Primary end point, % 14.1 11.5 11.4 0.76 Death, % 0.7 0.0 1.6 0.34 MI, % 3.0 0.8 2.9 0.43 UA, % 12.6 11.5 10.6 0.88 PCI, % 4.4 0.8 3.3 0.12 Repeat CABG, % 1.5 1.5 1.6 0.99 UA indicates unstable angina requiring rehospitalization; PCI, percutaneous coronary intervention; and MI, myocardial infarction. Primary end point is any-cause mortality, MI, or UA requiring hospitalization.
3072 Circulation June 26, 2001 TABLE 4. Complications and Adherence to Protocol by Patients Warfarin⫹Placebo Aspirin⫹Placebo Aspirin⫹Warfarin Complications (n⫽45) (n⫽46) (n⫽44) P Minor bleeding, % 8.9 1.5 9.8 0.02 Major bleeding, % 7.4 0.0 2.4 0.15 Blood transfusions, % 4.4 0 4.5 0.34 Compliance, % 90.0 86.7 86.1 0.66 Protocol completion, % 77.6 78.5 69.9 0.22 components of the end point were all less frequent in the lipid-lowering agents, ACE inhibitors, and antithrombotic aspirin-alone group. More frequent interventions were also therapy. Yet, medical management in the study remained performed during follow-up in patients receiving Coumadin, suboptimal, with 20% of the hyperlipemic patients not being although they were poor candidates for surgery, suggesting a on lipid-lowering therapy at the time of randomization, 25% lack of a benefit of the anticoagulation in preventing severe of patients with depressed LVEF not being on ACE inhibi- angina as well as recurrent ischemic events. tors, and 25% of the patients remaining active smokers. ACS in patients with previous CABG is usually associated With the premature discontinuation of the study and an with fibrin-rich blood clot,14 –16 more extensive coronary observed event rate less than expected, the sample size of the artery disease, and an impaired prognosis.2– 4 Other specific present study was suboptimal. It provided 60% power to features of high risk in the study population included mean detect a 15% risk difference, 70% power to detect a 20% risk age ⬎65 years, a high incidence of previous myocardial difference, and 88% power to detect a 25% difference infarction and of diabetes mellitus, a low LVEF (30⫾2%), between groups at a value of P⬍0.05. However, Coumadin and, most important, selection of patients evaluated as poor alone, compared with aspirin alone, was associated with an candidates for a new revascularization procedure by coronary increased absolute risk of 2.6%, and the combination of angiography and, for noncatheterized patients, by a coronary Coumadin with aspirin was associated with a minimal de- anatomy known to be poorly suitable for revascularization. crease of 0.1% (RR reduction of 0.87%), providing a low Despite these high-risk features, the primary end point in probability of a significant gain with Coumadin. A sample the present study was relatively infrequent, less than ex- size ⬎50 000 of patients would be required to document an pected, and composed primarily of recurrent unstable angina eventual benefit of the combination Coumadin⫹aspirin over with a relatively low rate of death or myocardial infarction. aspirin for a high futility index, assuming that the observed These figures are in contrast to those of previous studies, event rates were not confounded by an imbalance in the including one from our center, in which rates as high as 30% baseline characteristics of patients. Differences were indeed to 40% were reported.2,4 The improved prognosis possibly observed between groups, although they were not statistically reflects a more aggressive use of conventional and investiga- significant. Subanalysis of the results by variables influencing tive intervention procedures in patients with severe angina as prognosis did not influence results, and no favorable trends well as the progress made in medical therapy in recent years, with emphasis on drugs that achieve plaque passivation and emerged in any end point favoring Coumadin alone or in better control of the disease process. Such drugs include combination. However, it remains possible that the differ- ences observed, a combination of various differences, or other undetected differences could have had an impact on the results. Indeed, the univariate and multivariate analyses of determinants of prognosis suffered a similar lack of power as the outcome end points. Therefore, the present results should be interpreted as highly suggestive but not conclusive. Although no studies with aspirin and Coumadin have previously specifically addressed the specific population of patients with previous CABG developing an ACS, a large body of experience has been gained with aspirin, warfarin, and the combination in unstable angina and in CABG in general. The efficacy of aspirin in the prevention of death and myocardial infarction in patients with unstable angina has been well documented, as has the efficacy of aspirin in maintaining venous graft patency when initiated at the time of surgery.5–12 However, long-term benefits to maintain graft Cumulative rates of death, myocardial infarction, or recurrent patency are less well documented. Warfarin used alone can unstable angina requiring hospitalization during 12-month treat- prevent recurrence of unstable angina13 but has not been ment period (months 0 to 12) and during month after discontin- uation of study drugs and therapy with open-labeled aspirin shown to be more effective than aspirin in maintaining graft (ASA) (months 12 to 13). patency.8 –12
Huynh et al Aspirin and Warfarin in ACS With Prior CABG 3073 The combination of antiplatelet and antithrombotic therapy lowering of LDL cholesterol levels.18,20 Therefore, the treat- has been extensively studied. In a primary prevention trial in ment currently recommended for the management of ACS in high-risk men,17 low-intensity oral anticoagulation (INR 1.5) high-risk patients with previous CABG is aspirin, clopi- and low-dose aspirin (75 mg daily) had additive benefit. dogrel, ACE inhibitors, and an aggressive control of risk However, a low-intensity regimen was ineffective in large factors aided by lipid-lowering drugs. secondary prevention trials addressing patients with previous CABG18 and patients with a recent myocardial infarction,19 Acknowledgments although post-CABG patients appeared to have derived some The authors wish to thank Susan Nguyen for the statistical analyses, benefit, years after the discontinuation of Coumadin.20 The Marie-Andrée Séguin for data compilation, and the research coordi- combination therapy with moderate-intensity anticoagulation nators for patient recruitment and follow-up. to INR 2 to 3 might be more interesting. 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