Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

Abstract

A trial fibrillation (AF), the most common cardiac arrhythmia, occurs in 1% to 2% of the general population, with a prevalence varying from 0.5% in subjects 40 to 50 years old to 5% to 15% in the elderly who are >80 years old. [1][2][3] Stroke is the most feared complication of AF, resulting in death or disabling symptoms in a vast proportion of cases. 4 In the Framingham study, the age-adjusted incidence of stroke was 5-fold higher in subjects with AF, and the attributable risk raised from 1.5% at 50 to 59 years to 23.5% at 80 to 89 years. 5Chronic oral anticoagulation (OAC) therapy is the mainstay of stroke prevention in patients with AF at high risk for cardioembolic sequelae; ≈70% to 80% of all patients with AF have an indication for OAC, and coronary artery disease coexists in 20% to 30% of them. 6,7 With an estimated prevalence of AF in 1% to 2% of the population, it may be projected that ≈1 to 2 million patients on OAC in both the United States and Europe are candidates for coronary revascularization, often in the form of percutaneous coronary interventions (PCI). Patients undergoing PCI, as well as those who present with an acute coronary syndrome (ACS), also require dual antiplatelet therapy (DAPT), usually aspirin in combination with a platelet adenosine diphosphate P2Y 12 receptor antagonist, with the goal of reducing the risk of ischemic recurrences, including stent thrombosis. 8 However, the efficacy and safety of combining OAC with DAPT (triple antithrombotic therapy) in these patients is a topic of debate. In fact, although this combination can potentially prevent both thromboembolism and atherothrombotic events, it is also associated with an increased risk of severe bleeding. In a large nationwide registry of 40 812 patients hospitalized with myocardial infarction (MI), the risk of subsequent hospitalizations for bleeding increased with the number of antithrombotic drugs used, being 1.8-fold in patients on vitamin K antagonists (VKAs) and aspirin, 3.5-fold in patients on VKAs and clopidogrel, and 4-fold in patients on triple therapy, with numbers needed to harm of 45.4, 15.2, and 12.5, respectively. 9 On this background, treatment with OAC and antiplatelet agents requires careful consideration of the risks and benefits associated with each drug and their combination.On one hand, the challenge of balancing the risk of thromboembolism (ie, stroke) and atherothrombotic events (ie, stent thrombosis) and, on the other, the risk of bleeding demand for a timely review of the literature on using various combinations of OAC and antiplatelet therapies in patients with coexisting AF and coronary artery disease. This is also underscored by the recent availability of newer antithrombotic agents, including oral anticoagulants (ie, dabigatran, rivaroxaban, apixaban) and antiplatelets (ie, prasugrel, ticagrelor). This article reviews the evidence supporting antithrombotic agents for AF and ACS/PCI, and describes contemporary antithrombotic regimens and practical recommendations for patients with both condition...

Novel antiplatelet agents in acute coronary syndrome

“…169 In this setting, a strategy based on cessation of aspirin while maintaining dual therapy with clopi dogrel plus warfarin was safe and effective in a small, randomized trial. 170 The ongoing PIONEER AF-PCI 171 and REDUAL PCI 172 trials are expected to provide further insights on this topic.…”

Triple Antithrombotic Therapy in Atrial Fibrillation Patients With an Indication for Oral Anticoagulation Undergoing Percutaneous Coronary Intervention

“…The higher the risk, the more measures should be taken to avoid and prevent bleeding, such as use of low-dose aspirin use (≤100 mg), avoidance of nonsteroidal anti-inflammatory agent, the standardized use of a radial approach, smaller sheath size, BMS use, routine use of PPI, utilization of a target INR range of 2.0 to 2.5, 24 the choice and dose of antithrombotics and P2Y12 inhibitors, and avoidance of all of the following: use of glycoprotein IIb/IIIa inhibitors, periprocedural bridging with low molecular weight heparin, and crossing over from 1 antithrombotic to another, if not strictly indicated. 4,6,25,26 Dr Picard: In the case of our patient, what do the Guidelines say about antithrombotic therapy?…”

“…Finally, after PCI, tailored use of antithrombotic therapy should be determined in accordance with the available evidence, low-dose of aspirin (if introduced); warfarin dose should be adjusted and closely monitored to maintain the INR between 2 and 2.5; routine PPI use is highly recommended 6,16 when using TT; and doctor and pharmacist should avoid any nonsteroid anti-inflammatory administration. 26 Ideally, PPI with less cytochrome P450 2C19 (CYP2C19) inhibitory activity, as pantoprazole, should be used. The plasma concentrations of the clopidogrel active metabolite and the degree of platelet inhibition are less than observed with clopidogrel alone but greater than observed with omeprazole.…”

Triple therapy in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention/stenting

“…Data on concomitant use of prasugrel or ticagrelor in patients taking OACs are scarce, and the risk of bleeding with either of these drugs may be excessive in combination with aspirin in anticoagulated patients . Hence, clopidogrel is the preferred antiplatelet agent regarding PCI in patients with indications for OACs . Importantly, new‐generation drug‐eluting stents and radial approach should be used to minimize bleeding risk, while proton pump inhibitors should be considered in all patients receiving TT to minimize gastrointestinal bleeding .…”