How to Secure Diabetics with Atrial Fibrillation During PCI?

Percutaneous Coronary Intervention in Diabetics

According to the results of several studies, patients with diabetes and atrial fibrillation have a higher risk of ischemic stroke and a higher risk of severe bleeding compared to non-diabetics. Additionally, ischemic heart disease is known to be an independent risk factor for thromboembolic events in patients with atrial fibrillation. Therefore, patients with diabetes and atrial fibrillation undergoing percutaneous coronary intervention are at high risk for thromboembolic events. 

RE-DUAL Study

In the RE-DUAL PCI study (Randomized Evaluation of Dual Antithrombotic Therapy with Dabigatran versus Triple Therapy with Warfarin in Patients with Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention), the occurrence of severe bleeding and thromboembolic events (the sum of cases of death, myocardial infarction, systemic embolization, ischemic stroke, and unplanned revascularizations) was evaluated in patients with atrial fibrillation who underwent PCI. The study participants were randomized into three groups. The first and second groups received dual therapy with dabigatran at a dose of 110 mg or 150 mg twice daily in combination with clopidogrel or ticagrelor, while the third group was treated with triple therapy comprising warfarin with clopidogrel or ticagrelor and acetylsalicylic acid.

Sub-analysis Results in Diabetics

The study included 2724 patients, of whom 993 had diabetes. Diabetics more frequently had a history of ischemic stroke, PCI, and coronary bypass. The sum of deaths, thromboembolic events, and unplanned revascularizations during the study was also higher in this group.

Patients treated with dual therapy with dabigatran had a lower risk of bleeding compared to those treated with warfarin. This difference was more pronounced in the group receiving the 110 mg dose compared to the 150 mg dose.

The effectiveness (evaluated as the sum of deaths, thromboembolic events, and unplanned revascularizations) was comparable across all three drug combinations. The results for both diabetics and non-diabetics were similar, with the difference that in non-diabetics, significantly less bleeding occurred with dabigatran at both the 110 mg and 150 mg doses compared to warfarin.

Summary of Key Findings

The study demonstrated that patients with atrial fibrillation and diabetes face higher risks of death and thromboembolic events related to PCI, but have similar bleeding risks compared to non-diabetic patients. In diabetics, the efficacy and safety of all treatment methods were similar to the overall group. Dual therapy with dabigatran at a dose of 110 mg twice daily showed a lower risk of bleeding and was as effective as triple therapy with warfarin.

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Source: Maeng M., Steg P. G., Deepak L. B. et al. Dabigatran dual therapy versus warfarin triple therapy post-PCI in patients with atrial fibrillation and diabetes. JACC Cardiovasc Interv 2019; 12 (23): 2346–2355, doi: 10.1016/j.jcin.2019.07.059.