From the Guidelines
For patients on aspirin (ASA) and ticagrelor after myocardial infarction (MI) and percutaneous coronary intervention (PCI) who develop atrial fibrillation, the recommended approach is to continue the P2Y12 inhibitor (ticagrelor) while adding an oral anticoagulant such as apixaban, rivaroxaban, or warfarin, and discontinuing aspirin, as this dual therapy approach balances the need for stroke prevention in atrial fibrillation with the continued protection against stent thrombosis 1.
When considering the management of these patients, several key factors must be taken into account:
- The risk of stent thrombosis versus the risk of bleeding
- The type of stent used and its characteristics
- The patient's individual risk factors for bleeding and thrombosis
- The need for regular monitoring of bleeding complications and the potential use of proton pump inhibitors for gastrointestinal protection
The AUGUSTUS trial 1 demonstrated that apixaban was superior to vitamin K antagonists in reducing bleeding complications, while the PEGASUS-TIMI 54 trial 1 showed that ticagrelor reduced ischemic events in patients with a history of MI.
In terms of specific anticoagulant choices, apixaban, rivaroxaban, and warfarin are all options, with the choice depending on individual patient characteristics and preferences. The RE-DUAL PCI trial 1 and the PIONEER AF-PCI trial 1 provide evidence for the use of dabigatran and rivaroxaban, respectively, in this patient population.
Ultimately, the decision on the optimal antithrombotic regimen for patients on ASA and ticagrelor after MI and PCI who develop atrial fibrillation should be individualized, taking into account the patient's unique risk factors and characteristics, and made in consultation with a cardiologist.
From the Research
Medical Treatment for Atrial Fibrillation Post Myocardial Infarction and PCI
The medical treatment for patients on aspirin and ticagrelor post myocardial infarction and percutaneous coronary intervention (PCI) who then develop atrial fibrillation involves antithrombotic therapy.
- The use of ticagrelor in a dual therapy has been compared to aspirin and clopidogrel in bleeding events, with results showing that the incidence of total bleeding events in atrial fibrillation patients treated with ticagrelor was comparable to that in patients treated with clopidogrel plus aspirin at 6 months 2.
- Triple antithrombotic therapy, which includes oral anticoagulation (OAC), a P2Y12 inhibitor, and aspirin, is often recommended for patients with atrial fibrillation who undergo PCI or have an acute coronary syndrome event, but it has been shown to increase the risk of major bleeding complications 3.
- Studies have also investigated the use of ticagrelor monotherapy after a minimum period of dual antiplatelet therapy, with results showing that it can reduce the risk of bleeding after PCI, including in patients with an ST-elevation myocardial infarction (STEMI) 4, 5.
- Long-term treatment with ticagrelor and low-dose aspirin has been shown to have a favorable benefit/risk profile after acute coronary syndrome (ACS), with a low incidence of bleeding events and ischemic outcomes 6.
Antithrombotic Therapy Regimens
Different antithrombotic therapy regimens have been studied, including:
- Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, such as ticagrelor or clopidogrel
- Triple antithrombotic therapy with OAC, a P2Y12 inhibitor, and aspirin
- Ticagrelor monotherapy after a minimum period of DAPT Each regimen has its own benefits and risks, and the choice of therapy depends on the individual patient's risk factors and medical history 2, 3, 4, 5, 6.