Should a patient with a history of drug-eluting stent (DES), atrial fibrillation (AF), and previous stroke be on both anticoagulation and anti-platelet medication?

From the Guidelines

A patient with a history of drug-eluting stent (DES), atrial fibrillation (AF), and previous stroke should be on dual antithrombotic therapy consisting of an oral anticoagulant (OAC) and a P2Y12 inhibitor (P2Y12i), rather than triple antithrombotic therapy, to minimize bleeding risk while preventing thrombotic events. The recommended approach is oral anticoagulation with a direct oral anticoagulant (DOAC) such as apixaban (5mg twice daily), rivaroxaban (20mg daily), or dabigatran (150mg twice daily), as preferred over vitamin K antagonists (VKAs) like warfarin, except in specific cases 1. This should be combined with a single antiplatelet agent, preferably a P2Y12 inhibitor like clopidogrel 75mg daily, as part of dual antithrombotic therapy, which has been shown to be effective in reducing ischemic events without significantly increasing bleeding risk compared to triple therapy 1.

The decision to use dual antithrombotic therapy is based on the principle of minimizing bleeding risk while effectively preventing thrombotic events, as outlined in the 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease 1. The 2024 ESC guidelines for the management of atrial fibrillation also support the use of DOACs over VKAs and recommend against combining anticoagulants and antiplatelet agents unless necessary for acute vascular events or procedures 1.

Key considerations include:

• The use of DOACs as the preferred oral anticoagulants due to their efficacy and safety profile compared to VKAs.
• The selection of a P2Y12 inhibitor as the antiplatelet agent in dual antithrombotic therapy.
• The importance of assessing individual bleeding risk and adjusting the duration of antiplatelet therapy accordingly, with most patients able to discontinue antiplatelet therapy after 6-12 months post-stenting.
• Regular monitoring for bleeding complications and the use of gastroprotection with a proton pump inhibitor if necessary.
• The need for individualized treatment decisions, taking into account the patient's specific risk factors for thrombotic and bleeding events.

From the FDA Drug Label

The efficacy and safety of XARELTO 2.5 mg orally twice daily versus placebo on a background of aspirin 100 mg once daily in patients with PAD were evaluated in the COMPASS study A total of 27,395 patients were evenly randomized to rivaroxaban 2.5 mg orally twice daily plus aspirin 100 mg once daily, rivaroxaban 5 mg orally twice daily alone, or aspirin 100 mg once daily alone. Patients with established CAD or PAD were eligible Relative to placebo, XARELTO reduced the rate of the primary composite outcome of stroke, myocardial infarction or cardiovascular death: HR 0.76 (95% CI: 0.66,0.86; p=0.00004)

For a patient with a history of drug-eluting stent (DES), atrial fibrillation (AF), and previous stroke, the use of anticoagulation as well as anti-platelet medication is supported by the evidence.

• The COMPASS study 2 demonstrated that rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily reduced the rate of major cardiovascular events in patients with coronary artery disease (CAD) or peripheral artery disease (PAD).
• The study results suggest that the combination of anticoagulation and anti-platelet therapy may be beneficial in reducing the risk of stroke, myocardial infarction, and cardiovascular death in patients with a history of DES, AF, and previous stroke.
• However, the decision to use anticoagulation and anti-platelet therapy should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
• It is essential to weigh the benefits and risks of combination therapy, including the increased risk of bleeding, and to closely monitor the patient for any adverse events.

From the Research

Anticoagulation and Anti-Platelet Therapy for Patients with Atrial Fibrillation and Drug-Eluting Stent

• Patients with a history of drug-eluting stent (DES), atrial fibrillation (AF), and previous stroke often require both anticoagulation and anti-platelet therapies to reduce the risk of ischemic events and stroke 3, 4.
• The choice of antithrombotic therapy should be based on the individual patient's risk of stroke, stent thrombosis, and bleeding 5.
• Dual antithrombotic therapy (OAC plus a P2Y12-receptor inhibitor) may be a suitable option for patients with AF and DES, as it reduces bleeding risk without increasing the risk of ischemic events 3.
• For patients with a low risk of stroke, dual antiplatelet therapy alone may be sufficient, while those at moderate to high risk of stroke may require dose-adjusted oral anticoagulation 5.
• The use of a bare metal stent, proton pump inhibitors, and tight control of the international normalized ratio (INR) can help reduce bleeding risk 5.
• Recent trials have evaluated various regimens for up to one year for AF patients after coronary stenting or acute coronary syndrome, but little empiric evidence exists about the best antithrombotic strategy beyond one year 4.

Selection of Stent Type and Anticoagulant Therapy

• The selection of a drug-eluting stent (DES) versus a bare metal stent (BMS) can have important implications for patients with AF presenting with acute myocardial infarction, as DES placement was more common among patients at high stroke risk and high bleeding risk 6.
• Warfarin was prescribed less frequently among patients receiving a DES than a BMS, and the composite outcome was similar between patients with a DES or BMS at 1 year 6.
• New oral anticoagulants (dabigatran, apixaban, rivaroxaban) have been found to be as efficacious as warfarin and safer in terms of intracranial bleeding, and may be suitable options for stroke prevention in AF patients 7.

Considerations for Antithrombotic Therapy

• The risk of thromboembolism, cardiovascular events, and bleeding should be assessed individually for each patient with AF and stable coronary artery disease (≥1 year after coronary stenting or acute coronary syndrome) 4.
• For patients with low bleeding risk and high risk for cardiovascular events, antiplatelet therapy might be added to anticoagulant therapy 4.
• The management of bleeding complications while on new anticoagulants remains an area of concern, and management is based on anecdotal experience and observational studies 7.