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 [
[1]
,
- 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.
Circulation. 2019; (epublication ahead of print)https://doi.org/10.1161/CIR.0000000000000665
[2]
]. 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 [
- 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).
Europace. 2019; 21: 192-193
[3]
,
[4]
]. 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 [
[5]
].To read this article in full you will need to make a payment
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References
- 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation.Circulation. 2019; (epublication ahead of print)https://doi.org/10.1161/CIR.0000000000000665
- 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).Europace. 2019; 21: 192-193
- Stent thrombosis: a clinical perspective.JACC Cardiovasc Interv. 2014; 7: 1081-1092
- 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.Circulation. 2009; 119: 687-698
- Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation.N Engl J Med. 2019; 380: 1509-1524
- And now we have the AUGUSTUS–how will it impact on antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention?.Eur J Intern Med. 2019; ([in press])
- Dabigatran versus warfarin in patients with atrial fibrillation.N Engl J Med. 2009; 361: 1139-1151
- Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.N Engl J Med. 2011; 365: 883-891
- Apixaban versus warfarin in patients with atrial fibrillation.N Engl J Med. 2011; 365: 981-992
- Edoxaban versus warfarin in patients with atrial fibrillation.N Engl J Med. 2013; 369: 2093-2104
- Prevention of bleeding in patients with atrial fibrillation undergoing PCI.N Engl J Med. 2016; 375: 2423-2434
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Article info
Publication history
Published online: May 23, 2019
Accepted:
May 14,
2019
Received:
May 13,
2019
Identification
Copyright
© 2019 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
