Antithrombotic Management for Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention or With Acute Coronary Syndrome: An Evidence-Based Update

Abstract

Combined antithrombotic regimens for atrial fibrillation (AF) patients with coronary artery disease, particularly for those who have acute coronary syndrome (ACS) and/or are undergoing percutaneous coronary intervention (PCI), presents a great challenge in the real-world clinical scenario. Conventionally, a triple antithrombotic therapy (TAT), which consists of combined oral anticoagulant therapy to prevent systemic embolism or stroke along with dual antiplatelet therapy to prevent coronary arterial thrombosis (CAT), is used. However, TAT has been associated with a significantly increased risk of bleeding. With the emergence of non-vitamin K antagonist oral anticoagulants (NOACs), randomized controlled trials have demonstrated a better risk-to-benefit ratio of dual antithrombotic therapy (DAT) in combination of a NOAC and with a P2Y12 inhibitor than vitamin K antagonist-based TAT. The results of these studies have impacted the recommendations of current international guidelines, which favor a DAT with a NOAC and P2Y12 inhibitor (especially clopidogrel) in this clinical setting. Additionally, aspirin can be administered during the periprocedural period, while the treatment duration of TAT should be as short as possible. In this article, we summarize the up-to-date evidence regarding antithrombotic regimens for AF patients with PCI or ACS, with a specific focus on the optimal approach and critical discussions of key scientific data and future developments for antithrombotic management in these patients.

Evolving Antithrombotic Treatment Patterns for Patients With Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome or Underwent Percutaneous Coronary Intervention in China: A Cross-Sectional Study

“…This phenomenon demonstrated that clinical practice has been influenced by evolving evidence and guidelines recommendations, which is in line with the result from Taiwan (33). This paradigm shift in prescribing practice has been driven in part by the prevalence use of NOACs with a better risk-to-benefit ratio of NOAC-based DT than VKA-based TT (34). In addition, this trend might also be driven by the realization that DAPT alone was not sufficient for thromboembolism prevention (25).…”

Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation

“…‘Triple therapy’ is likely less prescribed by physicians due to concerns regarding bleeding risk. A greater risk-to-benefit ratio of DAT (DOAC plus a P 2 Y 12 inhibitor) in comparison to a VKA-based TAT has been shown in randomized controlled trials[ 101 , 102 ]. The Danish nationwide administrative registries showed that DOACs use exceeded that of warfarin, in any combination with antiplatelet drugs, by 2016[ 103 ].…”

Trends in Off-Label Indications of Non-Vitamin K Antagonist Oral Anticoagulants in Acute Coronary Syndrome

“…Five to 10% of patients presenting with ACS have AF and using oral anticoagulation therapy [ 47 ]. Patients with AF and ACS have less favourable clinical outcomes [ 46 , 48 ]. Patients with concurrent myocardial infarction and AF usually have higher stroke rate (3.1%) than those without AF (1.3%) [ 49 ].…”

“…Patients with concurrent myocardial infarction and AF usually have higher stroke rate (3.1%) than those without AF (1.3%) [ 49 ]. As ACS requires DAPT, the presence of AF makes it a challenging scenario where healthcare providers must balance risks and benefits of the indicated triple antithrombotic therapy (TAT) with regards to prevention of ischemic episodes, stroke, stent thrombosis, systemic embolism, and bleeding [ 48 ].…”