From the Guidelines
The recommended antithrombotic regimen for patients with atrial fibrillation undergoing percutaneous coronary intervention, as seen in the PIONEER-AF PCI trial, is low-dose rivaroxaban (15 mg once daily) plus a P2Y12 inhibitor (typically clopidogrel) for 12 months, or very-low-dose rivaroxaban (2.5 mg twice daily) plus dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y12 inhibitor for 1,6, or 12 months, followed by rivaroxaban 15 mg once daily plus aspirin until 12 months, as supported by the 2018 European Heart Rhythm Association practical guide 1.
Key Considerations
- The choice between these regimens should be individualized based on the patient's thrombotic and bleeding risks.
- Rivaroxaban doses should be adjusted for renal function, with 10 mg daily recommended for patients with creatinine clearance 30-50 mL/min, as noted in the PIONEER AF-PCI trial 1.
- The use of double antithrombotic therapy (OAC plus P2Y12 receptor inhibitor) after a short period of triple antithrombotic therapy is also recommended in the 2024 ESC guidelines for the management of chronic coronary syndromes 1.
- Ticagrelor or prasugrel should generally not be used as part of triple antithrombotic therapy, while ticagrelor, and possibly prasugrel, may be considered as part of double antithrombotic therapy, as stated in the 2024 ESC guidelines 1.
Benefits and Risks
- Both regimens showed similar efficacy to the traditional triple therapy approach (warfarin plus DAPT) but with significantly lower bleeding rates, as demonstrated in the PIONEER-AF PCI trial 1.
- The 2016 ESC guidelines for the management of atrial fibrillation also suggest that a short period of triple therapy (OAC, aspirin, clopidogrel) is recommended, followed by a period of dual therapy (OAC plus a single antiplatelet) 1.
- The results of five RCTs have shown that double compared with triple antithrombotic therapy reduced major or clinically relevant non-major bleeding, without a significant increase of ischemic events, leading to the recommended use of double antithrombotic therapy, as noted in the 2024 ESC guidelines 1.
From the Research
Antithrombotic Regimen for Patients with Atrial Fibrillation Undergoing PCI
The PIONEER-AF PCI trial and other studies provide evidence for the recommended antithrombotic regimen for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).
- The optimal antithrombotic strategy for patients with AF undergoing PCI is not fully established, but several studies suggest that dual antithrombotic therapy (DAT) with a non-vitamin K antagonist oral anticoagulant (NOAC) and a P2Y12 inhibitor is a suitable alternative to triple antithrombotic therapy (TAT) with warfarin, a P2Y12 inhibitor, and aspirin 2, 3, 4, 5, 6.
- A meta-analysis of antithrombotic therapy in patients with AF undergoing PCI found that apixaban + P2Y12 inhibitor had the lowest bleeding risk compared to other regimens, including other DOACs + P2Y12 inhibitors, with no increase in ischemic outcomes 2.
- The RE-DUAL PCI trial demonstrated that dual therapy with dabigatran and a P2Y12 inhibitor was associated with a lower risk of bleeding compared to triple therapy with warfarin, a P2Y12 inhibitor, and aspirin, with no difference in thromboembolic events 4.
- Current guidelines recommend a non-vitamin K antagonist oral anticoagulant as the oral anticoagulation of choice for patients with AF undergoing PCI, with dual antiplatelet therapy with aspirin and a P2Y12 inhibitor given during the peri-PCI period, followed by double therapy with a P2Y12 inhibitor and a non-vitamin K antagonist oral anticoagulant 6.
Key Findings
- Dual antithrombotic therapy with a NOAC and a P2Y12 inhibitor is a suitable alternative to triple antithrombotic therapy for patients with AF undergoing PCI.
- Apixaban + P2Y12 inhibitor has the lowest bleeding risk compared to other regimens.
- Dual therapy with dabigatran and a P2Y12 inhibitor is associated with a lower risk of bleeding compared to triple therapy with warfarin, a P2Y12 inhibitor, and aspirin.
- Current guidelines recommend a non-vitamin K antagonist oral anticoagulant and dual antiplatelet therapy with aspirin and a P2Y12 inhibitor for patients with AF undergoing PCI.