From the Guidelines
The most appropriate antithrombotic therapy for this 54-year-old man with atrial fibrillation who has undergone percutaneous coronary intervention (PCI) with a second-generation drug-eluting stent (DES) and has a low bleeding risk compared to the risk of stent thrombosis is triple therapy with a DOAC, aspirin, and clopidogrel for up to 1 month, followed by dual therapy with a DOAC and clopidogrel for up to 6 months. This approach is based on the latest guidelines from the European Heart Journal, which recommend initial low-dose aspirin once daily in addition to OAC and clopidogrel for patients with an indication for oral anticoagulation who undergo PCI 1. The use of a DOAC is preferred over a vitamin K antagonist (VKA) unless contraindicated, and the duration of triple therapy should be limited to minimize bleeding risk.
Key Considerations
- The patient's low bleeding risk relative to thrombosis risk supports the use of triple therapy for a short duration 1.
- The European Heart Journal guidelines recommend early cessation of aspirin (≤1 week) after uncomplicated PCI in patients with a concomitant indication for OAC, followed by continuation of OAC and clopidogrel for up to 6 months 1.
- The American College of Cardiology expert consensus decision pathway also recommends against the routine use of triple antithrombotic therapy for most patients, and suggests that dual antithrombotic therapy consisting of an AC and a P2Y12 inhibitor be the default strategy after recent PCI 1.
Treatment Strategy
- Triple therapy with a DOAC, aspirin, and clopidogrel for up to 1 month to provide maximal protection during the highest risk period for stent thrombosis.
- Dual therapy with a DOAC and clopidogrel for up to 6 months to balance the need for anticoagulation for stroke prevention in atrial fibrillation with the dual antiplatelet therapy needed to prevent stent thrombosis.
- Long-term management would typically involve a DOAC alone or with a single antiplatelet agent, depending on ongoing risk assessment.
From the Research
Antithrombotic Therapy for Atrial Fibrillation Patients Undergoing PCI
The management of antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is complex and requires careful consideration of the individual patient's risk profile.
- The optimal antithrombotic management of AF patients who require oral anticoagulation (OAC) undergoing PCI remains unclear 2.
- Current guidelines recommend dual antithrombotic therapy (DAT; OAC plus P2Y12 inhibitor) after a short course of triple antithrombotic therapy (TAT; DAT plus aspirin) 3.
Recommended Antithrombotic Regimens
- A non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice for patients with AF undergoing PCI 3.
- Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period, after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor in combination with a non-vitamin K antagonist oral anticoagulant (double therapy) 3.
- In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (triple therapy) for up to 1 month 3.
Bleeding and Ischemic Risk
- The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding 3.
- Dropping aspirin from the triple therapy regimen to create dual therapy (oral anticoagulants and P2Y12 inhibitors alone) has been shown to reduce bleeding without a significant increase in ischemic events 4.
- However, dual therapy is associated with an increased risk of stent thrombosis, myocardial infarction, and cardiovascular mortality compared to triple therapy 5.
Patient Selection and Individualized Assessment
- Careful patient selection and individualized assessment of the risk-benefit balance is warranted when deciding on antithrombotic therapy for patients with AF undergoing PCI 4.
- A careful consideration of the individual patient's risk profile, including their ischemic and bleeding risk, is necessary to optimize the net clinical balance in this population 5.