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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EResults of the first randomized trial to address optimal antiplatelet therapy in patients on oral anticoagulants (OACs) undergoing coronary stenting showed that treatment with dual antithrombotic therapy (OAC plus clopidogrel alone) caused less bleeding than triple antithrombotic therapy (OAC plus aspirin plus clopidogrel), with no excess of thrombotic\/thromboembolic events and less all-cause mortality. This article discusses the What Is the Optimal Antiplatelet and Anticoagulant Therapy in Patients with Oral Anticoagulation and Coronary Stenting [WOEST; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00769938\u0026amp;atom=%2Fspmdc%2F12%2F13%2F13.2.atom\u0022\u003ENCT00769938\u003C\/a\u003E] trial.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Clinical Trials\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EResults of the first randomized trial to address optimal antiplatelet therapy in patients on oral anticoagulants (OACs) undergoing coronary stenting showed that treatment with dual antithrombotic therapy (OAC plus clopidogrel alone) caused less bleeding than triple antithrombotic therapy (OAC plus aspirin plus clopidogrel), with no excess of thrombotic\/thromboembolic events and less all-cause mortality.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ELong-term OAC therapy is necessary in most patients with atrial fibrillation (AF) or a mechanical heart valve. The addition of aspirin and clopidogrel are indicated when these patients undergo percutaneous coronary intervention (PCI), but when all 3 drugs are coadministered, the risk of major bleeding is substantially increased [Sorensen et al. \u003Cem\u003ELancet\u003C\/em\u003E 2009]. In this context, the What Is the Optimal Antiplatelet and Anticoagulant Therapy in Patients with Oral Anticoagulation and Coronary Stenting [WOEST; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00769938\u0026amp;atom=%2Fspmdc%2F12%2F13%2F13.2.atom\u0022\u003ENCT00769938\u003C\/a\u003E] trial was designed to test the hypothesis that in patients on OAC therapy undergoing PCI, the addition of clopidogrel alone is superior to the combination of aspirin and clopidogrel with respect to bleeding. The results of the trial were presented by Willem Dewilde, MD, Twee Steden Hospital, Tilburg, the Netherlands.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EWOEST was an investigator-initiated, prospective, randomized study conducted in 15 Danish and Belgium hospitals between November 2008 and November 2011. Patients with a prior history of AF (69%), a mechanical heart valve (10%), or other indication for OAC (eg, thromboembolic disease or severe systolic heart failure) were openly randomized to either dual (warfarin+clopidogrel 75 mg QD; n=279) or triple (warfarin+clopidogrel 75 mg QD+aspirin 80 mg QD; n=284) therapy. Patients were treated with clopidogrel for a minimum of 1 month after placement of a bare-metal stent (\u223c30% of patients) and 1 year after placement of a drug-eluting stent (\u223c65%). All patients were followed for 1 year. The primary outcome was the occurrence of any bleeding event (Thrombolysis in Myocardial Infarction [TIMI] major or minor criteria), and the study was statistically powered to detect a 60% reduction in bleeding based on prior cohort data (annual expected bleeding rate on triple therapy was projected to be 12%). Secondary exploratory endpoints included ischemic events, a combination of stroke, death, myocardial infarction (MI); stent thrombosis (ST) and target vessel revascularization (TVR); and individual components of these endpoints [Dewilde W and Berg JT. \u003Cem\u003EAm Heart J\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EBaseline characteristics in the WOEST study revealed the mean age of patients was \u223c70 years, \u223c80% were men, \u223c70% had a history of hypertension, 70% had hypercholesterolemia, and 25% to 30% had a prior history of either diabetes, MI, or heart failure. Concurrent use of proton pump inhibitors was \u223c35%. Despite the exclusion of patients with a recent history of major bleeding, peptic ulcer disease, or other major risk factors, bleeding in this study was higher than expected (\u223c45% of patients assigned to triple therapy experienced a bleeding endpoint within 1 year). However, patients treated with dual therapy experienced significantly less bleeding compared with triple therapy (19.5% vs 44.9%; HR, 0.36; 95% CI, 0.26 to 0.50; p\u0026lt;0.001; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/13.2\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Primary Endpoint: Total Number of Bleeding Events (TIMI Criteria).\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1212511196\u0022 data-figure-caption=\u0022Primary Endpoint: Total Number of Bleeding Events (TIMI Criteria).\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/13.2\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/13.2\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/12\/13\/13.2\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/14184\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EPrimary Endpoint: Total Number of Bleeding Events (TIMI Criteria).\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ETIMI=thrombolysis in myocardial infarction.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from W. Dewilde, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EResults were consistent among major subgroups, including when analyzed by a threshold age of 75 years, gender, presentation with acute coronary syndrome, indication for OAC, and stent received. The difference in bleeding between the 2 treatment groups was driven predominantly by TIMI minimal and minor bleeding from the access site, gastrointestinal, and superficial locations. There was no difference between the 2 groups in TIMI major bleeding (3.3% vs 5.8%; p=0.159) or intracranial bleeds (3 in each group).\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EPatients receiving dual therapy experienced significantly fewer composite ischemic events compared with those receiving triple therapy (11.3% vs 17.7%; HR, 0.60; 95% CI, 0.38 to 0.94; p=0.025). Each component of the composite ischemic endpoint was consistently less frequent among patients assigned dual therapy except for TVR.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe investigators concluded that a strategy of omitting aspirin is an option in high-risk patients on chronic anticoagulation undergoing PCI. Although it was an open-label study, this provocative trial will hopefully open the door for further investigations of the optimal long-term treatment strategy to balance ischemic and bleeding outcomes in high-risk patients.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2012 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/12\/13\/13.2.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznb1f\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznb1f\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}