Commentary: Temporarily omitting oral anticoagulants early after stenting for acute coronary syndromes patients with atrial fibrillation

Abstract

The joint occurrence of atrial fibrillation (AF) and an acute coronary syndrome (ACS) entails a three-dimensional – cardioembolic, coronary and hemorrhagic – risk. Triple antithrombotic therapy (TAT), i.e., oral anticoagulation (OAC) on top of dual antiplatelet therapy (DAPT), has been the default strategy for such patients until recently. Due to the high hemorrhagic burden of TAT, several dual antithrombotic therapy (DAT) regimens, i.e., OAC plus a single antiplatelet agent, have been proposed in randomized trials with the aim of improving safety without hampering efficacy. Current guidelines and consensus documents still leave here, however, OAC as an undisputed cornerstone. Such documents do not sufficiently distinguish between the ischemic risk due to ACS treated with stenting and the one due to AF, which may dissociate in some patients and definitely have a different time course. The possibility of postponing the introduction of OAC in such conditions, rather taking advantage of the use of newer P2Y12 inhibitors prasugrel and ticagrelor, is not currently sufficiently contemplated in contemporary documents. We here question the claimed lack of alternatives to the “anticoagulant always and immediately” approach in most such patients, propose some risk simulations, claim that skipping anticoagulation in the presence of modern DAPT for one month after an ACS in the context of a high bleeding risk and a high coronary risk is a valuable, currently unlisted option, and raise the need of a proper trial on this controversial issue.