Dual therapy in a patient with atrial fibrillation at high risk of bleeding

Abstract

In patients with atrial fibrillation (AF) undergoing coronary angioplasty (PCI) the guidelines recommend the use of triple therapy (oral anticoagulant therapy in addition to dual antiplatelet therapy) for varying periods depending on the individual patient's risk profile, limiting the possibility of starting immediately with dual antithrombotic therapy to patients with relevant haemorrhagic risk. Triple therapy is associated with a high frequency of major bleeding; in recent years there have been several studies investigating new therapeutic strategies attempting to reduce the risk of bleeding without increasing the thrombotic risk. We report the case of an elderly patient suffering from hypertension, a previous acute coronary syndrome with anterior descending stenting and permanent AF treated with dabigatran 110 mg bid for 2 years. The patient is admitted to hospital for syncope with facio-brachio-crural hemiparesis associated with myocardial infarction; she is treated with idarucizumab and coronary angiography shows trivessel disease with acute occlusion of the right proximal coronary arteru. This case is an example of how in a patient with AF, in which the risk of bleeding increases 4-fold, the adoption of the dual therapy rather than the triple therapy immediately after the acute event (according to data from the RE-DUAL PCI) or after 1 month (according to the guidelines), can prove effective over the long term, ensuring adequate protection both from hemorrhagic events and from the risk of stent thrombosis (Cardiology).