Triple Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Stents

Abstract

ase presentation: A 76-year-old man with rate-controlled atrial fibrillation (AF), diabetes mellitus, and prior stroke who is receiving warfarin to prevent recurrent stroke presents to the emergency department with chest pain, elevated serum troponin, and an ECG that demonstrates ST depression in the precordial leads. Cardiac catheterization reveals an ulcerated plaque and partially obstructive thrombus in the left circumflex coronary artery. Percutaneous coronary intervention is performed with placement of 2 baremetal stents. What is the optimal antithrombotic therapy? What is the optimal antithrombotic therapy if the patient receives drug-eluting stents instead of bare-metal stents? Efficacy of Antithrombotic Therapy in Patients With AFMeta-analyses of randomized controlled trials in patients with nonvalvular AF indicate that oral vitamin K antagonist (VKA) therapy reduces the risk of stroke or systemic embolism by 64% compared with placebo and by 39% compared with aspirin. 1,2 In the ACTIVE trials (Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events), warfarin reduced the risk of stroke or systemic embolism by 42% compared with dual-antiplatelet therapy with the combination of aspirin and clopidogrel, 3 whereas dual-antiplatelet therapy reduced the risk by 28% compared with aspirin alone. 4 Recently, the RE-LY trial (Randomized Evaluation of Longterm anticoagulant therapY) showed that compared with warfarin the oral direct thrombin inhibitor, dabigatran etexilate given at a dose of 150 mg twice daily reduces stroke with less intracranial bleeding, and dabigatran 110 mg twice daily has similar efficacy with less bleeding. 5 Dabigatran etexilate is not yet approved for stroke prevention in AF.

Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome in the real world: Data from the Berlin AFibACS Registry

“…For prevention of stroke, these patients need anticoagulation therapy, and for prevention of further coronary events, they require dual antiplatelet therapy as recommended by current guidelines [5][6][7]. However, the combination of anticoagulation and dual antiplatelet therapy (triple therapy) may dramatically increase the risk of bleeding, with the incidence of bleeding being reported from 2% to 15% [5] and increased bleeding events will lead to longer therapy duration [8]. At the same time, ACS patients with major bleeding have greater risk of death than patients without bleeding [9,10].…”

Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI

“…A common guideline-supported practice is to combine all three drugs in a strategy known as triple therapy 6 ; however, this approach may result in excessive major bleeding, with rates of 2.2% within the first month and 4 to 12% within the first year of treatment. 7 Novel oral anticoagulants may provide advantages over vitamin K antagonists. Rivaroxaban, an oral factor Xa inhibitor, has been associated with a lower risk of stroke and systemic embolism than vitamin K antagonists among patients with nonvalvular atrial fibrillation, with similar rates of major bleeding but significantly lower rates of intracranial hemorrhage and fatal bleeding.…”

Paradigm shift in anticoagulation therapy, fueling the pump and preventing rhythm crisis

“…The rationale for the TRACT is based on the fact that these agents have their specialized advantages in reducing risks of thrombosis in patients undergoing placement of a first-generation drug eluting stent (DES) and ischemic stroke in patients with AF (2,3). Studies also reported exponential increase of risks of intracranial hemorrhage (ICH) with the VKA based TRACT within the first year of initiation (4). Indirect and multiple inhibition of factors (II, VII, IX, X, proteins S and C etc.)…”