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Navigating the treacherous waters of antithrombotic therapies in patients with atrial fibrillation and coronary artery disease: Lessons from AUGUSTUS

      Determining the optimal antithrombotic regimen to prevent ischemic events and bleeding presents a challenge to cardiologists in managing their patients with atrial fibrillation (AF) who experience an acute coronary syndrome (ACS) and/or undergo percutaneous coronary intervention (PCI). The general consensus is to continue oral anticoagulation (OAC) to prevent stroke and to modify antiplatelet intensity and/or duration to minimize bleeding; however, the optimal combination has yet to be identified [
      • January C.T.
      • Wann L.S.
      • Calikins H.
      • et al.
      2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation.
      ,
      • Lip G.Y.H.
      • Collet J.P.
      • Haude M.
      • et al.
      2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA).
      ]. The most common reason to use a strategy of OAC plus a P2Y12-inhibitor plus aspirin is the perception that this regimen reduces the risk of ischemic events, including stent thrombosis. The risk of stent thrombosis, a rare and frequently fatal complication, is higher in the first weeks following PCI prior to re-endothelialization of the stent struts and/or polymer material, and is of particular concern when PCI occurs in the prothrombotic setting of ACS [
      • Claessen B.E.
      • Henriques J.P.S.
      • Jaffer F.A.
      • Mehran R.
      • Piek J.J.
      • Dangas G.D.
      Stent thrombosis: a clinical perspective.
      ,
      • Aoki J.
      • Lansky A.J.
      • Mehran R.
      • et al.
      Early stent thrombosis in patients with acute coronary syndromes treated with drug-eluting and bare metal stents: the acute catheterization and urgent intervention triage strategy trial.
      ]. Over the past decade a number of randomized controlled trials, of which AUGUSTUS is the latest, have challenged the axiom that a combination of OAC plus dual antiplatelet therapy is required in all patients [
      • Lopes R.D.
      • Heizer G.
      • Aronson R.
      • et al.
      Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation.
      ].
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