Abstract

Combined antithrombotic regimens for atrial fibrillation (AF) patients with coronary artery disease, particularly for those who have acute coronary syndrome (ACS) and/or are undergoing percutaneous coronary intervention (PCI), presents a great challenge in the real-world clinical scenario. Conventionally, a triple antithrombotic therapy (TAT), which consists of combined oral anticoagulant therapy to prevent systemic embolism or stroke along with dual antiplatelet therapy to prevent coronary arterial thrombosis (CAT), is used. However, TAT has been associated with a significantly increased risk of bleeding. With the emergence of non-vitamin K antagonist oral anticoagulants (NOACs), randomized controlled trials have demonstrated a better risk-to-benefit ratio of dual antithrombotic therapy (DAT) in combination of a NOAC and with a P2Y12 inhibitor than vitamin K antagonist-based TAT. The results of these studies have impacted the recommendations of current international guidelines, which favor a DAT with a NOAC and P2Y12 inhibitor (especially clopidogrel) in this clinical setting. Additionally, aspirin can be administered during the periprocedural period, while the treatment duration of TAT should be as short as possible. In this article, we summarize the up-to-date evidence regarding antithrombotic regimens for AF patients with PCI or ACS, with a specific focus on the optimal approach and critical discussions of key scientific data and future developments for antithrombotic management in these patients.

Highlights

  • Atrial fibrillation (AF) is a common atrial arrhythmia, which is prevalent in the elderly

  • Practical recommendations for the treatment for atrial fibrillation (AF)-percutaneous coronary intervention (PCI) patients were issued in the 2020 European Society of Cardiology (ESC) Guidelines for the Diagnosis and Management of AF Developed in Collaboration with the European Association of Cardio-Thoracic Surgery (EACTS) [11]

  • During a mean follow-up duration of 14 months, this study showed that the incidence of the composite end point of major or clinical relevant non-major (CRNM) bleeding was significantly smaller in patients allocated to either of the dabigatran dual therapy arms than among those assigned to the triple therapy arm

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Summary

INTRODUCTION

Atrial fibrillation (AF) is a common atrial arrhythmia, which is prevalent in the elderly. Patients with AF have increased risks of thromboembolic complications, including stroke and other cardiovascular events [1]. Antithrombotic therapy has become a cornerstone for the management of patients with AF. Many AF patients have comorbidities of coronary artery disease (CAD), antithrombotic regimens for these patients pose a great challenge. Anti-thrombus in AF With PCI/ACS antithrombotic regimen should be effective in decreasing the thrombotic events with remarkably increased bleeding risk. Physicians must carefully focus on choosing a treatment strategy that can balance the risks of ischemic stroke (IS), thromboembolism, coronary ischemic event recurrence, and stent thrombosis (ST) with the risk of antithromboticrelated bleeding, which makes determination of the optimal antithrombotic regimens and durations a great dilemma in realworld clinical practice [2]

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