Triple troubles selecting optimal therapy for atrial fibrillation patients undergoing percutaneous coronary interventions

In everyday clinical practice, over 80% of all patients with atrial fibrillation (AF) have an indication for an oral anticoagulant (OAC), and vascular disease may co-exist in ~30% of them [1]. Estimates suggest an AF prevalence of approximately 3% in adults [2], and ~20% of these require percutaneous cardiovascular interventions over time [3]. Hence ~1–2 million AF patients in Europe who are on OAC may undergo percutaneous coronary interventions (PCI), usually including stent implantation [4].
Antithrombotic therapy, with dual antiplatelet therapy (DAPT) consisting of low-dose acetylsalicylic acid and P2Y12 platelet receptor inhibitor, is the mainstay to reduce the risk of recurrent ischaemic events during the first year after PCI [5], while OAC therapy is the cornerstone in the prevention of ischaemic stroke in AF patients, and it is able to prolong life in these patients [6]. Particular challenging in terms of antithrombotic treatment are patients who present with both AF and coronary artery disease who underwent PCI, since clinicians need to balance the triple risks of ischaemic stroke, recurrent cardiac ischaemia, and bleeding (Figure 1).
According to current guidelines, combination triple therapy (TT) with aspirin, clopidogrel and an oral anticoagulant (up to 6 months) is recommended either after an acute coronary syndrome (ACS), or after elective coronary stenting for stable coronary artery disease in AF patients at moderate or high risk of stroke [7].
This scenario requires careful consideration of antithrombotic therapy optimization because co-prescription of OAC with dual antiplatelet therapy increases the absolute risk of major haemorrhage [8] given the fact that, in addition to the risk of triple therapy itself, most often these patients are elderly with multiple comorbidities.
Data pertaining to this growing proportion of AF po­pulation are scarce due to the paucity of dedicated trials in patients who are difficult to enrol and less keen to participate in controlled randomized studies [9]. In addition, trials testing antithrombotic drugs usually exclude these patients according to the study protocols.
The first randomized controlled trials (RCTs) to address the optimal antiplatelet therapy in patients on OAC with a vitamin K antagonist (VKA) undergoing coronary stenting was the WOEST trial, which compared dual therapy (VKA plus clopidogrel) to triple therapy (VKA plus aspirin and clopidogrel) in 573 patients taking...


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