Triple Oral Antithrombotic Therapy in Atrial Fibrillation and Coronary Artery Stenting

Abstract

Patients with atrial fibrillation affected by an acute coronary syndrome have indications for oral anticoagulation and dual antiplatelet therapy with aspirin and a P2Y 12 adenosine diphosphate receptor inhibitor after coronary artery stenting. The concurrent use of all 3 agents, termed triple oral antithrombotic therapy, significantly increases the risk of bleeding. To date, there is a lack of evidence on the proper combination and duration of anticoagulant and antiplatelet agents in patients with indications for both therapies. As such, care has been guided by expert opinion, and there is wide variation in clinician practice. In this review, the latest evidence on the risks and benefits of triple oral antithrombotic therapy in patients with atrial fibrillation after coronary artery stenting is summarized. We discuss the clinical risk scores useful in guiding the prediction of stroke, bleeding, and stent thrombosis. Additionally, we highlight where additional evidence is needed to determine the proper balance of anticoagulant and antiplatelet agents in this patient population.

One‐Year Outcome of Patients With Atrial Fibrillation Undergoing Coronary Artery Stenting: An Analysis of the AFCAS Registry

“…In contrast with most of the literature reporting a consistent increase in bleeding with TT compared to DAPT, no differences were seen in our population. The relatively small size, especially of the DAPT group, should be considered when trying to explain this discrepancy with previous studies …”

“…The contrasting observation of a large and significant reduction in the incidence of bleeding with VKA/C compared to TT reported in the recent WOEST study may again be related to methodological features. Among them, the open‐label design may have lead to an over‐reporting of bleeding events, which were 3‐ to 4‐fold higher than the average incidences reported in the literature, and in our study, and also much higher than the incidence anticipated at the time of sample size calculation . In contrast with most of the literature reporting a consistent increase in bleeding with TT compared to DAPT, no differences were seen in our population.…”

“…Among them, the open‐label design may have lead to an over‐reporting of bleeding events, which were 3‐ to 4‐fold higher than the average incidences reported in the literature, and in our study, and also much higher than the incidence anticipated at the time of sample size calculation . In contrast with most of the literature reporting a consistent increase in bleeding with TT compared to DAPT, no differences were seen in our population. The relatively small size, especially of the DAPT group, should be considered when trying to explain this discrepancy with previous studies …”

“…In contrast with most of the previous literature consistently showing that TT is associated with less MACCE but more bleeding compared to other antithrombotic regimens, we observed comparable efficacy and safety of TT, DAPT, and VKA/C. Whereas this discrepancy may be accounted for by the heterogeneity in design, indications for VKA and PCI‐S, combinations and doses of antithrombotic agents, and follow‐up durations of previous studies, it is of note that our findings are in accordance with more recent data derived from large, Danish, nationwide registries, where a comparable overall efficacy of TT, DAPT, and VKA/C on the occurrence of MACCE in AF patients undergoing PCI‐S has been reported . The lowest prevalence of patients with a CHADS 2 score ≥2 (in whom oral anticoagulation is warranted) in the DAPT group compared to the other 2 groups including VKA (ie, TT and VKA/C) should also be taken into account when considering the comparable incidence of stroke observed in our population.…”

New Antithrombotics for Secondary Prevention of Acute Coronary Syndrome

“…There is no evidence that low‐dose rivaroxaban combined with dual antiplatelet therapy would reduce the risk of stroke in patients with AF and ACS, and warfarin therapy may be preferred over any novel oral anticoagulant in this setting . There is currently considerable variation in adoption of triple antithrombotic therapy in patients with coexisting AF and ACS . Future studies with rivaroxaban, such as A Study Exploring Two Treatment Strategies of Rivaroxaban and a Dose‐Adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects With Atrial Fibrillation Who Undergo Percutaneous Coronary Intervention (PIONEER AF‐PCI; http://www.clinicaltrials.gov: NCT01830543), may provide insight into how to treat patients with AF who develop ACS, or vice versa, and may therefore lead to rivaroxaban being an important option to treat such patients in the future.…”