Difficult decision making in the management of patients with atrial fibrillation and acute coronary syndrome or invasive cardiovascular interventions: new recommendations for daily practice.

Abstract

This editorial refers to ‘Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS).' by Lip et al. , on page 3155–3179. In a series of clinical scenarios decision making on the most appropriate treatments to be applied in an individual patient may become very difficult, in view of the risk of treatment-related adverse events that have to be balanced against the benefits that a specific medication or intervention may offer. When a clinician has to decide on use of antithrombotic drugs in the setting of a patient affected by atrial fibrillation (AF) experiencing an acute coronary syndrome (ACS), the difficult task is avoiding thrombotic events (stroke prevention, recurrent cardiac ischaemia in an ACS setting, stent thrombosis if one is implanted) against the risk of haemorrhage when oral anticoagulant (OAC) is combined with antiplatelet therapy. This is really challenging, like the navigation between Scylla and Charybdis in the Strait of Messina, between Calabria and Sicily in Italy.1 In a patient with AF the need to decide on antithrombotic therapy is common in clinical practice, whereby according to current guidelines2 an indication for OACs can be present in over 80% of AF patients; however, 30% of them having vascular disease and around 20% requiring a percutaneous cardiovascular intervention (PCI) at some stage.3 On the other hand, previously undetected …