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Antithrombotic treatment in anticoagulated atrial fibrillation patients undergoing percutaneous coronary intervention

Published:January 06, 2017DOI:https://doi.org/10.1016/j.ejim.2017.01.001

      Highlights

      • Patients with AF after PCI should be treated with the anticoagulant and DAPT.
      • The optimal combination of DAPT and DOAC reduces the risk of stroke and ACS.
      • The treatment with DOAC and DAPT is can be safe to avoid bleeding complications
      • Switching from VKA to DOAC is an easy and safe process.

      Abstract

      Coronary artery disease coexists in a clinically relevant number of patients with atrial fibrillation and it often requires percutaneous coronary intervention. These patients represent a particular challenge for clinicians in terms of antithrombotic management. They require combined antiplatelet–anticoagulant therapy to reduce the risk of recurrent ischemic cardiac events and stroke; however, this antithrombotic strategy is associated with an increased risk of bleeding complications. In the absence of randomized, controlled clinical trials, the majority of current recommendations rely on the results of cohort studies, meta-analyses, post-hoc analyses and subgroup analyses of large, phase III studies. Based on the available evidence, the present review discusses the optimal antithrombotic strategy for patients receiving chronic anticoagulant therapy due to atrial fibrillation who require antiplatelet treatment after acute coronary syndrome and/or percutaneous coronary intervention, and discusses the issue of dental procedures. The correct planning of therapy significantly reduces the risk of bleeding complications and thromboembolic events.

      Key messages

      In order to reduce the occurrence of recurrent cardiac ischemic events and stroke, anticoagulated patients with acute coronary syndrome and/or percutaneous coronary intervention require a combination of therapies including anticoagulants and antiplatelet drugs.
      Using the newest optimal combination of therapeutic strategies reduces the risk of haemorrhagic complications.

      Abbreviations:

      ACC/AHA (American College of Cardiology/American Heart Association), ACS (acute coronary syndrome), AF (atrial fibrillation), APPRAISE 2 (The Apixaban for Prevention of Acute Ischemic Events 2), ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation), ATLAS-ACS 2–TIMI (Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Standard Therapy in Subjects with Acute Coronary Syndrome–Thrombolysis in Myocardial Infarction), CABG (coronary artery bypass graft), CrCl (creatinine-clearance), DAPT (dual antiplatelet therapy), DOAC (direct oral anticoagulant), ESC (European Society of Cardiology), GI (gastrointestinal), MI (myocardial infarction), NSTEMI (non ST-segment elevation myocardial infarction), OAC (oral anticoagulant), PCI (percutaneous coronary intervention), PIONEER AF-PCI ((Rivaroxaban) Study in Patients with Non-Valvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention with Stent Placement), RE-DEEM (Dabigatran vs. placebo in patients with acute coronary syndromes on dual antiplatelet therapy: a randomized, double-blind, phase II trial.), RE-DUAL (Evaluation of Dual Therapy With Dabigatran vs. Triple Therapy With Warfarin in Patients With AF That Undergo a PCI With Stenting), ROCKET AF (The Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation), STEMI (ST-segment elevation myocardial infarction), VKA (vitamin K antagonist), WOEST (What is the Optimal antiplatElet and Anticoagulant Therapy in Patients With Oral Anticoagulation and Coronary StenTing)

      Keywords

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