Tseng AS, Shamoun FE, Marks LA, Agrwal N. Antithrombotic Therapy for Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention. J Am Osteopath Assoc 2020;120(5):345–349. doi: https://doi.org/10.7556/jaoa.2020.053.
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1. What is the clinical question? What combination antithrombotic therapy is recommended for patients with atrial fibrillation with acute coronary syndrome or patients undergoing percutaneous coronary intervention?
2. What does the evidence say? Double therapy (DT) with clopidogrel and direct oral anticoagulants (specifically, dabigatran, rivaroxaban, and apixaban) is noninferior to warfarin-based therapies for most patients. Double therapy is noninferior to triple therapy (TT) and has less bleeding complications.
3. What is the take-home message for physicians? According to the latest guidelines by the ACC, AHA, ESC, and HRS, in patients with AF undergoing PCI, DT with DOACs (specifically dabigatran, rivaroxaban and apixaban) plus clopidogrel is acceptable. Patients undergoing PCI or with high ischemic risk may still benefit from TT for at least 1 month and up to 6 months before switching to DT. Currently, there is no specific guidance on long-term antiplatelet therapy in these patients. Duration of antiplatelet therapy, whether with DT or TT, should be based on current DAPT guidelines (depending on indication and type of intervention) and discussions with each patient's cardiologist.
Abbreviations: ACC, American College of Cardiology; ACS, acute coronary syndrome; AF, atrial fibrillation; AHA, American Heart Association; DAPT, dual antiplatelet therapy; DT, double therapy; DOAC, direct oral anticoagulant; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; NS, not significant; PCI, percutaneous coronary intervention; RCT, randomized controlled trial; SIHD, stable ischemic heart disease; TT, triple therapy.
a Although warfarin can be used, based on the available randomized controlled trial evidence, direct oral anticoagulants (DOACs) cause less bleeding compared with warfarin. This consideration is not formally recommended in current guidelines.
Abbreviations: ACS, acute coronary syndrome; DT, double therapy; PCI, percutaneous coronary intervention; SIHD-BMS, stable ischemic heart disease bare-metal stent; SIHD-DES, SIHD drug-eluting stent; TT, triple therapy.
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