Antithrombotic Management in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation

Atrial fibrillation (AF) and/or the need for oral anticoagulation (OAC) frequently coexist with stable chronic coronary syndrome (CCS). In this population, clinicians must carefully balance ischemic protection against bleeding risk. This review aims to synthesize available evidence and address whether antiplatelet therapy (APT) should be maintained on top of OAC in this specific subset.

Recent trials have provided key evidence. AFIRE, EPIC-CAD, AQUATIC and ADAPT-AF-DES have all demonstrated that OAC monotherapy is not only non-inferior but also superior to combination therapy (OAC plus APT) in terms of net clinical benefit, with fewer major bleeding events and no increase in ischemic complications. The AQUATIC and AFIRE trials even showed an excess in mortality with prolonged combination therapy. Current evidence supports OAC alone as the preferred long-term antithrombotic strategy in patients with AF and stable CCS.