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Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous
Dominick J Angiolillo1, Deepak L Bhatt2, Christopher P Cannon2
1Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.).
Insights
For patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI), non-vitamin K antagonist oral anticoagulants are recommended. Guidelines suggest dual antiplatelet therapy initially, followed by a P2Y12 inhibitor and oral anticoagulant for optimal antithrombotic management.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Increasing number of patients with atrial fibrillation undergo percutaneous coronary intervention (PCI).
- Optimal antithrombotic management is challenging due to dual therapy requirements (oral anticoagulation and dual antiplatelet therapy).
- Combined therapies significantly increase bleeding risk.
Observation:
- Recent pivotal clinical trials have been published since the 2018 consensus statement.
- Updated recommendations focus on antithrombotic therapy for atrial fibrillation patients undergoing PCI.
- Non-vitamin K antagonist oral anticoagulants are preferred for oral anticoagulation.
Findings:
- Dual antiplatelet therapy (aspirin and P2Y12 inhibitor) is recommended during the peri-PCI period.
- Post-PCI, the default strategy is aspirin cessation, continuing a P2Y12 inhibitor (preferably clopidogrel) with a non-vitamin K antagonist oral anticoagulant (double therapy).
- Triple therapy (including aspirin) may be considered for up to 1 month in high thrombotic risk patients with acceptable bleeding risk.
Implications:
- Double therapy is recommended for 6-12 months, tailored to individual ischemic and bleeding risk.
- Discontinuation of antiplatelet therapy after 6-12 months, continuing oral anticoagulation alone, is advised.
- These updated guidelines aim to balance thrombotic prevention with bleeding risk reduction in this complex patient population.
Abstract:
A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor, preferably clopidogrel, in combination with a non-vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.
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