What is the recommended management for a patient with coronary artery disease (CAD) and atrial fibrillation (AF)?

Management of Coronary Artery Disease and Atrial Fibrillation

For patients with both coronary artery disease (CAD) and atrial fibrillation (AF), oral anticoagulation is the cornerstone of therapy, with CAD recognized as a moderate risk factor that supports anticoagulation use, and the specific antithrombotic regimen depends critically on whether the patient has stable CAD versus acute coronary syndrome (ACS) or recent percutaneous coronary intervention (PCI). 1

Anticoagulation Strategy for Stable CAD with AF

For patients with stable CAD and AF who have not undergone recent PCI, oral anticoagulation alone (without antiplatelet therapy) is the recommended long-term strategy. 1

• Direct oral anticoagulants (DOACs) are preferred over warfarin due to lower risk of intracranial hemorrhage and superior efficacy for stroke prevention 2
• Rivaroxaban 20 mg once daily has demonstrated particular benefit in preventing stroke/systemic embolism in this population 2
• Apixaban 5 mg twice daily (or 2.5 mg twice daily if dose-reduction criteria are met) shows advantages in reducing major bleeding and all-cause mortality 2
• Warfarin with target INR 2.0-3.0 remains an acceptable alternative, particularly in patients with mechanical heart valves or mitral stenosis 1

The presence of CAD alone (without recent ACS or PCI) does not mandate adding aspirin to anticoagulation, as this increases bleeding risk without proven mortality benefit. 1

Management After PCI or ACS

Elective PCI with Bare-Metal Stent

Following elective PCI with bare-metal stent placement, triple therapy (oral anticoagulant + aspirin ≤100 mg + clopidogrel 75 mg) should be administered for 1 month, followed by dual therapy (oral anticoagulant + clopidogrel 75 mg) up to 12 months, then oral anticoagulant monotherapy lifelong. 1

• Drug-eluting stents should be avoided when possible in AF patients requiring anticoagulation, but if used, triple therapy duration extends to 3-6 months depending on stent type 1
• For '-olimus' type drug-eluting stents (sirolimus, everolimus, tacrolimus), triple therapy should continue for at least 3 months 1
• For paclitaxel-eluting stents, triple therapy should continue for at least 6 months 1

Acute Coronary Syndrome

For patients presenting with ACS (STEMI or NSTEMI), triple therapy should be used for 6 months regardless of stent type, followed by dual therapy up to 12 months, then oral anticoagulant monotherapy. 1

• In the acute setting, unfractionated heparin, low-molecular-weight heparin, or bivalirudin may be added, with glycoprotein IIb/IIIa inhibitors reserved as "bail-out" options 1
• Radial access is preferred during PCI to reduce bleeding risk 1
• An uninterrupted anticoagulation strategy is preferred for patients at moderate-to-high thromboembolic risk (INR 2.0-3.0 maintained throughout procedure) 1

Bleeding Risk Stratification

Patients at high bleeding risk (HAS-BLED score ≥3) require shortened triple therapy duration. 1

• For elective PCI with bare-metal stent in high bleeding risk patients: 2-4 weeks of triple therapy, then oral anticoagulant monotherapy lifelong 1
• For ACS in high bleeding risk patients: 4 weeks of triple therapy, then dual therapy up to 12 months, then oral anticoagulant monotherapy 1
• Gastric protection with proton pump inhibitors should be considered for all patients on combination antithrombotic therapy 1

Rate Control in AF with CAD

Beta-blockers are the preferred first-line agents for rate control in AF patients with CAD, providing both rate control and anti-ischemic benefits. 3, 4

• Target resting heart rate <110 bpm for lenient control or <80 bpm for strict control 4
• For patients with preserved ejection fraction (LVEF >40%), beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) are appropriate 4, 5
• For patients with reduced ejection fraction (LVEF ≤40%), beta-blockers and/or digoxin are recommended, avoiding calcium channel blockers due to negative inotropic effects 4, 5

Critical Pitfalls to Avoid

• Never use AV nodal blockers (digoxin, diltiazem, verapamil, amiodarone) in patients with Wolff-Parkinson-White syndrome and pre-excited AF, as they can accelerate ventricular rate and precipitate ventricular fibrillation 1, 4
• Do not discontinue anticoagulation after successful cardioversion in patients with stroke risk factors—long-term anticoagulation decisions are based on CHA₂DS₂-VASc score, not rhythm status 4
• Avoid combining aspirin with anticoagulation long-term in stable CAD without recent PCI, as this significantly increases bleeding risk without mortality benefit 1
• Do not use type IC antiarrhythmic drugs (flecainide, propafenone) in patients with structural heart disease or CAD due to proarrhythmic risk 1, 4

Monitoring Requirements

• INR should be monitored weekly during warfarin initiation, then monthly when stable 1
• Renal function should be assessed at least annually in patients on DOACs, more frequently if clinically indicated 4, 5
• Reassess anticoagulation need and bleeding risk regularly, but do not withhold anticoagulation based solely on bleeding risk scores 4