What are the recommendations for combined antiplatelet and Direct Oral Anticoagulant (DOAC) therapy in patients with Coronary Artery Disease (CAD)?

Recommendations for Combined Antiplatelet and DOAC Therapy in Coronary Artery Disease

In patients with CAD requiring both antiplatelet therapy and oral anticoagulation, dual therapy with a DOAC plus clopidogrel is recommended over triple therapy due to significantly lower bleeding risk while maintaining similar protection against ischemic events.

General Principles

The management of patients requiring both antiplatelet therapy and anticoagulation requires careful consideration of both thrombotic and bleeding risks. The evidence-based approach includes:

For Patients with CAD and Atrial Fibrillation Undergoing PCI:

1. Initial Triple Therapy Period:

   • Triple therapy (DOAC + aspirin + clopidogrel) should be limited to ≤1 week after PCI 1
   • This short period of triple therapy is only needed during the immediate post-PCI period when stent thrombosis risk is highest

2. Transition to Dual Therapy:

   • After the initial period, continue with DOAC + clopidogrel for:
     • Up to 6 months in patients not at high ischemic risk
     • Up to 12 months in patients at high ischemic risk 1

3. Long-term Management:

   • After 6-12 months, discontinue antiplatelet therapy and continue with DOAC monotherapy 1
   • Discontinuation of antiplatelet treatment in patients treated with OAC should be considered at 12 months 1

DOAC Selection and Dosing:

• When a DOAC is used in combination with antiplatelet therapy, use the lowest approved dose effective for stroke prevention 1:
  • Rivaroxaban 15 mg daily (instead of 20 mg) when combined with antiplatelet therapy 1, 2
  • Apixaban 5 mg twice daily or 2.5 mg twice daily (if meeting dose reduction criteria)
  • Dabigatran 110 mg twice daily (instead of 150 mg) when combined with antiplatelet therapy

P2Y12 Inhibitor Selection:

• Clopidogrel is the preferred P2Y12 inhibitor when combined with oral anticoagulation 1
• The use of ticagrelor or prasugrel is generally not recommended as part of triple antithrombotic therapy with aspirin and OAC 1

Special Considerations

High Ischemic Risk Patients:

Patients with high ischemic risk features may benefit from longer duration of dual therapy (DOAC + antiplatelet) and include those with:

• Stenting of left main, proximal LAD, or last remaining patent artery
• Suboptimal stent deployment
• Stent length >60 mm
• Bifurcation with two stents implanted
• Treatment of chronic total occlusion 1

High Bleeding Risk Patients:

For patients at high bleeding risk:

• Consider even shorter duration of triple therapy (<1 week)
• Consider dual therapy with DOAC and clopidogrel from the outset, omitting aspirin 1
• Use proton pump inhibitor for the duration of combined antithrombotic therapy 1

Stable CAD vs. ACS

Stable CAD:

• For patients with stable CAD on DOAC for AF, antiplatelet therapy can often be discontinued after the initial post-PCI period (6-12 months) 1
• In stable CAD without recent PCI, DOAC monotherapy is generally sufficient without antiplatelet therapy 1

Acute Coronary Syndrome:

• After ACS, dual therapy with DOAC plus clopidogrel should be continued for 6-12 months depending on bleeding risk 1
• After this period, transition to DOAC monotherapy 1

Important Cautions

1. Avoid ticagrelor or prasugrel with OAC:

   • These more potent P2Y12 inhibitors significantly increase bleeding risk when combined with anticoagulation 1

2. Monitor bleeding risk closely:

   • The combination of DOAC and antiplatelet therapy increases bleeding risk 2-3 fold compared to DOAC alone 1

3. Reassess therapy regularly:

   • The decision for DAPT duration should be dynamic and reassessed during the course of the initially selected regimen 1

4. Use appropriate DOAC dosing:

   • When combined with antiplatelet therapy, consider using the lower approved DOAC doses to minimize bleeding risk 1, 2

By following these evidence-based recommendations, clinicians can optimize the balance between preventing thrombotic events and minimizing bleeding complications in patients with CAD requiring both antiplatelet and anticoagulant therapy.