Antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting: Suggested strategies tailored to an integrated evaluation of different risk profiles

The optimal antithrombotic therapy for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention with stent (PCI-S) is still undetermined [ , ]. Current recommendations, however generally based on a level of evidence C (i.e. derived from experts' opinion and/or non-randomized, small-size data), suggest triple therapy (TT) with either a vitamin K-antagonist (VKA) or non-vitamin K antagonist oral anticoagulant (NOAC) plus aspirin and clopidogrel as the preferred strategy to prevent both thromboembolic and ischemic cardiac events [ , ]. Owing to the well documented increase in bleeding complications of TT and the high safety (with no apparent impaired efficacy) of dual therapy (DT) with VKA plus clopidogrel reported in the WOEST trial [ ], this latter regimen, possibly also to be extended to NOACs, may be considered in patients at increased bleeding risk and concomitant no significant elevation of ischemic cardiac risk [ , ]. The recent publication of the PIONEER AF-PCI trial [ ] has provided additional evidence on the management of antithrombotic therapy in patients with AF undergoing PCI-S, also investigating for the first time a NOAC, namely rivaroxaban, being part of the combined antithrombotic therapy for this specific setting of patients. In the PIONEER AF-PCI trial, patients were randomized to receive DT with rivaroxaban 15 mg/day and a P2Y12 inhibitor, essentially clopidogrel, or TT with either very low dose rivaroxaban (2.5 mg twice/day) or warfarin (target International Normalized Ratio 2.0–3.0) plus aspirin and clopidogrel. The results of the PIONEER AF-PCI trial indicated a significantly lower bleeding risk in both arms receiving rivaroxaban, where the intensity of the antithrombotic treatment was reduced either because only one antiplatelet agent was given or the dose of the anticoagulant as part of TT was extremely low. Of note, the 15 mg daily dose of rivaroxaban is lower than that used in the ROCKET-AF trial [ ], in which rivaroxaban was given at the dose of 20 mg (reduced to 15 mg only in presence of creatinine clearance 30–49 ml/min), and resulted at least non-inferior to warfarin in preventing thromboembolic complications, with similar major bleeding rates and significant decrease of intracranial hemorrhages. Moreover, the ATLAS-2 trial [ ], performed on patients with acute coronary syndrome, demonstrated lower incidence of cardiovascular events and cardiovascular death with rivaroxaban 2.5 mg twice a day compared to placebo on top of dual antiplatelet therapy.