Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Coronary Stenting

Abstract

Abstract-The optimal regimen of the anticoagulant and antiplatelet therapies in patients with atrial fibrillation who have had a coronary stent is unclear. It is well recognized that "triple therapy" with aspirin, clopidogrel, and warfarin is associated with an increased risk of bleeding. National guidelines have not made specific recommendations, given the lack of adequate data. In choosing the best antithrombotic options for a patient, consideration needs to be given to the risks of stroke, stent thrombosis, and major bleeding. This executive summary describes these risks, provides specific recommendations concerning vascular access, stent choice, concomitant use of proton pump inhibitors, and the use and duration of triple therapy after stent placement, based on the risk assessment. (Circ Cardiovasc Interv. 2011;4:522-534.)Key Words: atrial fibrillation Ⅲ antithrombotic therapy Ⅲ warfarin Ⅲ triple therapy Ⅲ stent T he optimal regimen of the anticoagulant and antiplatelet therapies in patients with atrial fibrillation (AF) who have had a coronary stent is unclear. 1,2 It is estimated that 5-7% of patients undergoing percutaneous coronary interventions (PCI) have AF or other indications for chronic oral anticoagulant therapy. 3-5 These patients pose a significant dilemma for the interventional cardiologist because the combination of oral anticoagulants with aspirin and clopidogrel ("triple therapy") during follow-up has been reported to result in an increase risk of major bleeding. 6 Major bleeding is a serious complication that is associated with increased morbidity and mortality particularly when it occurs shortly after a stent procedure. 7,8 In one study among patients on triple therapy with aspirin, clopidogrel, and warfarin, major bleeding occurred in 4.7%, and approximately 50% of these patients died within 6 months. 9 Editorial see p 410The American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ ESC) guidelines have been cautious to recommend triple therapy (aspirin, clopidogrel, and oral anticoagulation) in patients with AF undergoing PCI due to the increased bleeding risk and limited information about the safety and efficacy of this treatment regimen. 10 Currently, the use of triple therapy is classified as a class IIb recommendation (may be considered) with a level of evidence C (expert opinion). 10,11 Recently, the ESC Working Group on Thrombosis published a consensus document on the management of these patients. 12,13 The authors conducted a careful review of the available studies and made a number of specific recommendations that have been supported by the ESC guidelines for the management of AF. 14 They tempered these recommendations since they were largely based on expert opinion. The current document provides a North American view of the issues and is the opinion of select experts in the United States and Canada. Because much of the background information has been previously published in the ESC consensus document, prior studies will not be extensively ...

Dual Antiplatelet Therapy and Outcomes in Patients With Atrial Fibrillation and Acute Coronary Syndromes Managed Medically Without Revascularization: Insights From the TRILOGY ACS Trial

“…1 In patients with stable coronary artery disease, the prevalence of AF is 12.5% 2 -4 and is associated with a higher risk of cardiovascular outcomes. 5 Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y 12 receptor inhibitor, is standard of care following percutaneous coronary intervention (PCI) for patients with acute coronary syndromes (ACS). However, a substantial proportion of these patients have AF, for which oral anticoagulants (OACs) provide superior prevention of stroke compared with antiplatelet agents; but, when combined with DAPT, they may significantly increase the risk of bleeding, specifically when prescribed with a newer P2Y 12 receptor inhibitor such as prasugrel or ticagrelor.…”

“…5 Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y 12 receptor inhibitor, is standard of care following percutaneous coronary intervention (PCI) for patients with acute coronary syndromes (ACS). However, a substantial proportion of these patients have AF, for which oral anticoagulants (OACs) provide superior prevention of stroke compared with antiplatelet agents; but, when combined with DAPT, they may significantly increase the risk of bleeding, specifically when prescribed with a newer P2Y 12 receptor inhibitor such as prasugrel or ticagrelor. 6 -11 Patients with both AF and ACS present a clinical conundrum, given uncertainty regarding the optimal antithrombotic strategy, as well as for those undergoing PCI ( 12,13 and to date there are no studies analyzing the association between AF and outcomes among ACS patients at highest risk-specifically, elderly patients managed medically without coronary revascularization.…”

“…However, a substantial proportion of these patients have AF, for which oral anticoagulants (OACs) provide superior prevention of stroke compared with antiplatelet agents; but, when combined with DAPT, they may significantly increase the risk of bleeding, specifically when prescribed with a newer P2Y 12 receptor inhibitor such as prasugrel or ticagrelor. 6 -11 Patients with both AF and ACS present a clinical conundrum, given uncertainty regarding the optimal antithrombotic strategy, as well as for those undergoing PCI ( 12,13 and to date there are no studies analyzing the association between AF and outcomes among ACS patients at highest risk-specifically, elderly patients managed medically without coronary revascularization. The randomized Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRIL-OGY ACS; NCT00699998) trial included a prospective analysis plan to evaluate the prognostic role of AF in elderly patients with ACS.…”

Antithrombotic therapy and bleeding risk in atrial fibrillation. Fewer unanswered questions

“…Triple therapy (TT) and the other combinations of OAC plus one antiplatelet drug are basically indicated in patients with AF with acute coronary syndrome (ACS) and/or coronary stenting (16)(17)(18). Importantly, coronary artery disease is present in around 20-30% of patients with AF (19).…”

“…Nonetheless, patients with AF presenting with an ACS or with chronic ischaemic heart disease undergoing percutaneous coronary intervention with stent implantation represent a complex management problem (17,18,20). It is recognised that TT increases the risk of bleeding, and Azoulay et al (15) confirm this, by show-ing an 80% increased risk of bleeding when compared to warfarin monotherapy.…”