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Published on: February 26, 2013
Managing antithrombotic therapy in patients with both atrial fibrillation and coronary heart disease
Peter L Thompson1, Freek W A Verheugt2
1Heart Research Institute, Sir Charles Gairdner Hospital and University of Western Australia, Perth, Western Australia, Australia.
Insights
Managing atrial fibrillation (AF) and coronary heart disease (CHD) requires careful consideration of anticoagulants and antiplatelet agents. Evidence suggests aspirin withdrawal may reduce bleeding risk in some patients without increasing coronary events.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Atrial fibrillation (AF) and coronary heart disease (CHD) frequently coexist.
- Existing guidelines predate novel oral anticoagulants (NOACs) and newer P2Y12 inhibitors.
- Management strategies for combined AF and CHD require updated evidence.
Purpose of the Study:
- To review recent evidence for managing patients with both AF and CHD.
- To guide treatment decisions in stable CHD, recent acute coronary syndrome, and post-stent placement.
- To address the use of NOACs and newer antiplatelet agents in this population.
Main Methods:
- Literature search of PubMed and international meeting reports.
- Critical review of recent clinical trials and registry data.
- Synthesis of evidence to update consensus recommendations.
Main Results:
- Oral anticoagulation is essential for stroke prevention in AF.
- Aspirin monotherapy is standard for stable CHD.
- Dual-antiplatelet therapy is crucial after acute coronary syndrome or stenting.
- Combining antithrombotic agents increases bleeding risk.
- Limited evidence suggests aspirin withdrawal may reduce bleeding without increasing coronary events.
Conclusions:
- There is a significant lack of evidence for managing combined AF and CHD.
- Aspirin withdrawal in triple therapy (warfarin, aspirin, clopidogrel) may reduce bleeding.
- Further clinical trials are urgently needed for newer antithrombotic combinations.
Purpose:
Atrial fibrillation (AF) and coronary heart disease (CHD) commonly occur together. Previous consensus guidelines were published before the wide availability of novel oral anticoagulants (NOACs) and newer P2Y12 antiplatelet agents. We examine recent evidence to guide management in 3 categories of patients with AF and CHD: patients with stable CHD, nonstented patients with recent acute coronary syndrome, and patients with a coronary stent requiring dual-antiplatelet therapy.
Methods:
We conducted a literature search by evaluation of PubMed and other data sources including international meeting reports. We critically reviewed recent clinical trial and relevant registry evidence to update European and US consensus documents.
Findings:
Oral anticoagulation with warfarin or NOACs is required to prevent embolic stroke in AF, and antiplatelet therapy is insufficient for this purpose. Antiplatelet therapy using monotherapy with aspirin is the standard of care in stable CHD. Dual-antiplatelet therapy with aspirin and clopidogrel or a new P2Y12 inhibitor (dual-antiplatelet therapy) is needed to reduce coronary events after an acute coronary syndrome or after percutaneous coronary intervention. Combinations of these agents increase the risk of bleeding, and limited clinical trial evidence suggests that withdrawal of aspirin may reduce bleeding without increasing coronary events.
Implications:
Available clinical trials and registries provide remarkably little evidence to guide difficult clinical decision making in patients with combined AF and CHD. In patients on triple antithrombotic therapy with vitamin K antagonists, aspirin, and clopidogrel, a single clinical trial indicates that withdrawal of aspirin may reduce bleeding risk without increasing the risk of coronary thrombosis. It is unclear whether this evidence applies to combinations of NOACs and newer P2Y12 inhibitors. Clinical trials of combinations of the newer antithrombotic agents are urgently needed to guide clinical care.
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