Antithrombotic Treatment after Carotid Stenting in Patients with Concomitant Atrial Fibrillation

Antithrombotic therapy following carotid artery stent placement with concomitant atrial fibrillation is not well-established. Our aim was to assess the safety and efficacy of the combination of direct oral anticoagulants and a P2Y12 inhibitor at 30 days after carotid artery stent placement in patients with atrial fibrillation.

We designed an observational single-center study including patients who underwent carotid artery stent placement with concomitant atrial fibrillation. We studied 3 groups according to antithrombotic therapy: 1) the direct oral anticoagulants plus clopidogrel (DC) group: receiving direct oral anticoagulants plus a P2Y12 inhibitor; 2) the triple therapy group: anticoagulation and dual antiplatelet therapy; and 3) the dual antiplatelet therapy group: following dual antiplatelet therapy alone. The safety outcome was a major or clinically relevant non-major bleeding event at the first month. The efficacy outcomes were the thromboembolic events (myocardial infarction, stroke, systemic embolism, or stent thrombosis).

Of 959 patients with carotid artery stent placement, 91 met the inclusion criteria, including 24 patients in the DC group, 42 patients in the triple therapy group, and 25 in the dual antiplatelet therapy group. The mean age was 72.27 (SD, 8.1 ) years, with similar baseline characteristics. The median CHA₂DS₂-VASc score for each group was 6 (interquartile range  = 5-6), 5 (interquartile range = 4-6), and 5 (interquartile range = 4-6), respectively. The median HAS-BLED score was 4 in the 3 groups (P = .17). The primary safety end point was 23.8% in the triple therapy group compared with 4% in the dual antiplatelet therapy group (P = .032), with no bleeding events in the DC group (P = .007). There was 1 stent thrombosis in DC group and a cardioembolic stroke in the dual antiplatelet therapy group (P = .41).

Among patients with carotid artery stent placement with atrial fibrillation, triple therapy confers a high bleeding risk. A regimen of direct oral anticoagulants plus a P2Y12 inhibitor might confer a good safety profile with significantly lower rates of bleeding and optimal efficacy.