Atrial fibrillation medical therapy in patients presenting with ACS and/or PCI or valve intervention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Oral anticoagulation therapy with either vitamin K antagonist (VKA) or non-oral anticoagulants (NOAC) is the mainstay of the stroke prevention therapy among patients with atrial fibrillation (AF). Antithrombotic therapy consisting of dual antiplatelet drugs is administered among patients with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI) or those undergoing valvular intervention. A challenge in the treatment decision exists among atrial fibrillation patients who present with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI) or those those require valvular interventions. In this category of patients, the treatment regimen should be chosen carefully in order to achieve a balance between ensuring prevention of stroke and ischemic events and not increasing the risk of bleeding. In order to choose a treatment regimen for atrial fibrillation patients who present with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI) or those those require valvular interventions, the risk of stroke and the risk of bleeding must be assessed using CHA2DS2-VASc score and HAS-BLED score, respectively.

Atrial Fibrillation in Patients Presenting with ACS and/or PCI or Valve Intervention

Medical Therapy

Shown below are algorithms depicting the recommended treatment regimens and duration among atrial fibrillation patients who present with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI) or those those require valvular interventions according to the 2014 joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Triple therapy consisting of oral anticoagulant and dual antiplatelet therapy is considered among selected patients. Recent findings from the WOEST trial has contributed to challenge triple therapy by omitting aspirin without increasing ischemic events. Large scale randomized clinical trials are needed to accurately determine the best regimen that ensures protection against thromboembolic and ischemic events without increasing the bleeding risk.

Low or Moderate Risk of Stroke

Abbreviations: ACS: acute coronary syndrome; CAD: coronary artery disease; OAC: oral anticoagulant; PCI: percutaneous coronary intervention

Low or moderate risk of stroke (CHA2DS2-VASC = 1)

Determine the risk of bleeding

Low or moderate bleeding risk (HAS-BLED 0–2)

High bleeding risk (HAS-BLED ≥3)

Determine the clinical setting

Determine the clinical setting

PCI performed for stable CAD

ACS

PCI performed for stable CAD

ACS

At least 4 weeks (no longer than 6 months) Triple therapy: OAC + aspirin 75–100 mg/day + clopidogrel 75 mg/day* Up to 12th month OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day)** Lifelong OAC§

6 months Triple therapy: OAC + aspirin 75–100 mg/day + clopidogrel 75 mg/day Up to 12th month OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) Lifelong OAC§

12 months OAC and clopidogrel 75 mg/day** Lifelong OAC§

4 weeks Triple therapy: OAC + aspirin 75–100 mg/day + clopidogrel 75 mg/day§§ Up to 12th month OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) Lifelong OAC§

* Alternative regimen: OAC + clopidogrel 75 mg/day, or aspirin 75 mg/day + clopidogrel 75 mg/day

** Alternative regimen: aspirin 75 mg/day + clopidogrel 75 mg/day

^§ OAC in combination with an antiplatelet agent in cases of recurrent MI, stenting of a proximal bifurcation or left main

^§§ Alternative regimen: OAC + clopidogrel 75 mg/day

High Risk of Stroke

Abbreviations: ACS: acute coronary syndrome; CAD: coronary artery disease; OAC: oral anticoagulant; PCI: percutaneous coronary intervention

High risk of stroke (CHA2DS2-VASC ≥2)

Determine the risk of bleeding

Low or moderate bleeding risk (HAS-BLED 0–2)

High bleeding risk (HAS-BLED ≥3)

Determine the clinical setting

Determine the clinical setting

PCI performed for stable CAD

ACS

PCI performed for stable CAD

ACS

At least 4 weeks (no longer than 6 months) Triple therapy: OAC + aspirin 75–100 mg/day + clopidogrel 75 mg/day§§ Up to 12th month OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) Lifelong OAC§

6 months Triple therapy: OAC + aspirin 75–100 mg/day + clopidogrel 75 mg/day Up to 12th month OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) Lifelong OAC§

4 weeks Triple therapy: OAC + aspirin 75–100 mg/day + clopidogrel 75 mg/day* Up to 12th month OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) Lifelong OAC§

4 weeks Triple therapy: OAC + aspirin 75–100 mg/day + clopidogrel 75 mg/day§§ Up to 12th month OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) Lifelong OAC§

* Alternative regimen: OAC + clopidogrel 75 mg/day, or aspirin 75 mg/day + clopidogrel 75 mg/day

** Alternative regimen: aspirin 75 mg/day + clopidogrel 75 mg/day

^§ OAC in combination with an antiplatelet agent in cases of recurrent MI, stenting of a proximal bifurcation or left main

^§§ Alternative regimen: OAC + clopidogrel 75 mg/day

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation (DO NOT EDIT)

AF Complicating Acute Coronary Syndrome

Class I

"1. Urgent direct-current cardioversion of new-onset atrial fibrillation in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control. (Level of Evidence: C)"

"2. Intravenous beta blockers are recommended to slow a rapid ventricular response to atrial fibrillation (AF) in patients with acute coronary syndromes (ACS) who do not display heart failure, hemodynamic instability, or bronchospasm. (Level of Evidence: C)"

"3. For patients with acute coronary syndromes (ACS) and atrial fibrillation (AF) with CHA2DS2-VASc score of 2 or greater, anticoagulation with warfarin is recommended unless contraindicated. (Level of Evidence: C)"

Class IIb

"1. Administration of amiodarone or digoxin may be considered to slow a rapid ventricular response in patients with acute coronary syndromes (ACS) and atrial fibrillation (AF) associated with severe LV dysfunction and heart failure or hemodynamic instability. (Level of Evidence: C)"

"2. Administration of nondihydropyridine calcium antagonists might be considered to slow a rapid ventricular response in patients with acute coronary syndromes (ACS) and atrial fibrillation (AF) only in the absence of significant heart failure or hemodynamic instability. (Level of Evidence: C)"

2014 Management of Antithrombotic Therapy in AF Patients Presenting with ACS and/or Undergoing PCI or Valve Interventions: A Joint Consensus Document (DO NOT EDIT)

General

Class I

"1. In atrial fibrillation (AF) patients, stroke risk must be assessed using the CHA2-DS2-VASc score, and bleeding risk assessed using the HAS-BLED score. Risk stratification is a dynamic process, and must be performed at regular intervals (i.e. on a yearly basis). (Level of Evidence: C)"

"2. Where adjusted dose of vitamin K antagonist is used, good quality anticoagulation control is recommended, with a TTR >70%. (Level of Evidence: A)"

Class III

"1. Novel P2Y12 receptor inhibitors (prasugrel and ticagrelor) should not be part of a triple therapy regimen in patients with atrial fibrillation (AF). (Level of Evidence: C)"

Class IIa

"1. When vitamin K antagonist is given in combination with clopidogrel and/or low-dose aspirin, the dose intensity of vitamin K antagonist should be carefully regulated, with a target INR range of 2.0–2.5. (Level of Evidence: Grade C)"

"2. In a patients with atrial fibrillation (AF) and stable vascular disease (arbitrarily defined as being free from any acute ischemic event or repeat revascularization for >1 year) the patient should be managed with OAC alone (i.e. whether NOAC or a vitamin K antagonist). (Level of Evidence: Grade B)"

"3. Radial access should be considered as the default for coronary angiography/intervention to minimize the risk of access related bleeding depending on operator expertise and preference. (Level of Evidence: Grade C)"

Class IIb

"1. Where a NOAC is used in combination with clopidogrel and/or low-dose aspirin, the lower tested dose for stroke prevention in atrial fibrillation (AF) (that is, dabigatran 110 mg b.i.d., rivaroxaban 15 mg o.d. or apixaban 2.5 mg b.i.d.) may be considered (Prescribing information for edoxaban awaited.). (Level of Evidence: Grade C)"

"2. New generation drug eluting stent (DES) may be preferred over bare metal stent (BMS) in patients at low risk of bleeding (i.e. HAS-BLED 0–2). (Level of Evidence: Grade C)"

Stable CAD

Class I

"1. Long-term antithrombotic therapy with OAC (i.e. whether NOAC or a vitamin K antagonist) (beyond 12 months) is recommended in all patients. (Level of Evidence: B)"

Class IIa

"1. In patients with stable CAD and atrial fibrillation (AF) undergoing PCI at low bleeding risk (HAS-BLED 0–2), triple therapy (OAC, aspirin 75–100 mg daily, clopidogrel 75 mg daily) should be given for a minimum of 4 weeks (and no longer than 6 months) after PCI following which dual therapy with OAC (i.e. whether NOAC or a vitamin K antagonist) and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) should be continued for up to 12 months. (Level of Evidence: Grade C)"

"2. In selected patients with a CHA2DS2-VASc score= 1 (by virtue of their vascular disease only) at low-bleeding risk (HAS-BLED 0–2), dual antiplatelet therapy consisting of aspirin 75–100 mg and clopidogrel 75 mg/day; or dual therapy consisting of OAC(i.e. whether NOAC or a vitamin K antagonist) and clopidogrel 75 mg/day should be considered. (Level of Evidence: Grade C)"

"3. In patients with stable CAD and atrial fibrillation undergoing PCI at high bleeding risk (HAS-BLED .3), triple therapy (OAC, aspirin 75–100 mg daily, clopidogrel 75 mg daily) or dual therapy consisting of OAC(i.e. whether NOAC or a vitamin K antagonist) and clopidogrel 75 mg/day should be given for 4 weeks after PCI following which dual therapy with NOAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day) should be continued for up to 12 months. (Level of Evidence: Grade C)"

"4. Gastric protection with Proton pump inhibitor (PPIs) should be considered in patients with OAC plus antiplatelet therapy. (Level of Evidence: Grade C)"

"5. Where OAC patients are at moderate-to-high risk of thromboembolism (i.e. CHA2DS2-VASc ≥2), an uninterrupted anticoagulation strategy with no additional heparin boluses during PCI is the preferred strategy and radial access used as the first choice during therapeutic anticoagulation with a vitamin K antagonist (INR 2–3). This strategy might reduce periprocedural bleeding and thromboembolic events. (Level of Evidence: Grade C)"

Class IIb

"1. Dual therapy of OAC (i.e. whether NOAC or a vitamin K antagonist) and clopidogrel 75 mg/day may be considered as an alternative to initial triple therapy in selected patients with CHA2DS2-VASc score ≥2. (Level of Evidence: Grade C)"

"2. In selected patients with a CHA2DS2-VASc score = 1 at high-bleeding risk (HAS-BLED >3), dual antiplatelet therapy consisting of aspirin 75–100 mg and clopidogrel 75 mg/day; or dual therapy consisting of OAC (i.e. whether NOAC or vitamin K antagonist) and clopidogrel 75 mg/day may be considered for 12 months. (Level of Evidence: Grade C)"

"3. Combination OAC plus single antiplatelet therapy (preferably clopidogrel 75 mg/day or alternatively, aspirin 75–100 mg/day) may be considered in only very selected cases, e.g. stenting of the left main, proximal left anterior descending, proximal bifurcation, recurrent MIs, etc.. (Level of Evidence: Grade C)"

"4. Where NOAC patients are at moderate-to-high risk of thromboembolism (i.e. CHA2DS2-VASc ≥2), cessation of the drug for 48 h and parenteral anticoagulation as per standard practice during PCI may be prudent in a non-emergency situation. (Level of Evidence: Grade C)"

"5. When the procedures require interruption of OAC for longer than 48 h in high-risk patients (i.e. TAVI or other non-PCI procedures at high-bleeding risk), enoxaparin may be administered subcutaneously, although the efficacy of this strategy is uncertain. Pharmacodynamic data suggest that enoxaparin might be a better option than UFH, because of the more predictable and stable level of anticoagulation. Such ‘bridging’ therapies may actually be associated with an excess bleeding risk, possibly due to dual modes of anticoagulation in the overlap periods. When NOACs are used, timing of any bridging therapy should be tailored on the basis of renal function and the pharmacokinetics of the specific NOAC. (Level of Evidence: Grade C)"

NSTE-ACS Including Unstable Angina and NSTEMI

Class I

"1. Long-term antithrombotic therapy (beyond 12 months) is recommended with OAC whether with Vitamin K antagonist or a NOAC in all patients. (Level of Evidence: B)"

Class IIa

"1. Patients with moderate-to-high-risk NSTE-ACS and atrial fibrillation at low risk of bleeding (HAS-BLED 0–2) should receive dual antiplatelet therapy with aspirin plus clopidogrel and OAC (i.e. whether NOAC or a vitamin K antagonist) should also be given/continued. (Level of Evidence: Grade C)"

"2. An early invasive strategy (within 24 h) should be preferred among patients with moderate-to-high-risk NSTE-ACS in order to expedite treatment allocation (medical vs. PCI vs. CABG) and to determine the optimal antithrombotic regimen. (a) Pre-treatment with glycoprotein (GP) IIb/IIIa inhibitors should be avoided in such patients. (b) Pre-treatment with P2Y12 receptor antagonists may be withheld until the time of coronary angiography in case of an early invasive strategy within 24 h. (Level of Evidence: Grade C)"

"3. When a parenteral anticoagulant is needed to support PCI in a patient at high risk of bleeding, bivalirudin should be considered as an alternative to unfractionated heparin. (Level of Evidence: Grade A)"

"4. When a parenteral anticoagulant is needed to support PCI in a patient at low risk of bleeding, bivalirudin should be considered as alternative to unfractionated heparin. (Level of Evidence: Grade B)"

"5. In patients with Acute coronary syndromes (ACS) and atrial fibrillation at low risk of bleeding (HAS-BLED 0–2), the initial use of triple therapy (OAC, aspirin, and clopidogrel) should be considered for 6 months following PCI irrespective of stent type; this should be followed by long-term therapy (up to 12 months) with OAC and clopidogrel 75 mg/ day (or alternatively, aspirin 75–100 mg/day). (Level of Evidence: Grade C)"

"6. In patients with ACS and atrial fibrillation at high risk of bleeding (HAS-BLED ≥3), the initial use of triple therapy (OAC, aspirin, and clopidogrel) should be considered for 4 weeks following PCI irrespective of stent type; this should be followed by long-term therapy (up to 12 months) with OAC and a single antiplatelet drug (preferably clopidogrel 75 mg/day, or as an alternative, aspirin 75–100 mg/day). (Level of Evidence: Grade C)"

Class IIb

"1. In the ACS setting, patients are often given aspirin, clopidogrel, heparin (whether UFH or enoxaparin) or bivalirudin and/or a GP IIb/IIIa inhibitors. Given the risk of ischaemia and bleeding it may be prudent to stop OAC (i.e. whether NOAC or a Vitamin K antagonist) therapy, and where a Vitamin K antagonist or NOAC is used, administer UFH or bivalirudin only as bailout (but avoiding GP IIb/IIa inhibitors) or if INR ≤2 in a patient on Vitamin K antagonist, balancing the acute need for additional antithrombotic therapy with the excess bleeding risk and the ‘thrombus burden’. (Level of Evidence: Grade C)"

"2. In low-risk ACS patients with delayed transfer for an invasive strategy at >24 h of admission, it may be prudent to stop OAC therapy and bridge the patient with unfractionated heparin or enoxaparin. (Level of Evidence: Grade C)"

"3. For a NOAC, cessation of the drug for 36–48 h (based on the biological half-life of the respective agents and the actual kidney function) may be prudent. (Level of Evidence: Grade B)"

"4. In selected patients with a CHA2DS2-VASc score ≥2 at low risk of bleeding (HAS-BLED 0–2), continuation of triple therapy or dual antiplatelet therapy consisting of OAC (i.e. whether NOAC or a vitamin K antagonist) and clopidogrel 75 mg/day may be considered between 6 and 12 months. (Level of Evidence: Grade C)"

"5. As an alternative to initial triple therapy in selected patients at high risk of bleeding (e.g. HAS-BLED ≥3) and low risk of stent thrombosis/recurrent ischaemic events, dual therapy consisting of OAC and clopidogrel 75 mg/day may be considered. (Level of Evidence: Grade C)"

"6. Combination OAC plus single antiplatelet therapy (preferably clopidogrel 75 mg/day, or as an alternative, aspirin 75–100 mg/day) may be considered in very selected cases, e.g. stenting of the left main, proximal left anterior descending, proximal bifurcation, recurrent MIs, etc. (Level of Evidence: Grade B)"

"7. The use of ticagrelor or prasugrel in combination with OAC may only be considered under certain circumstances (e.g. definite stent thrombosis while on clopidogrel, aspirin, and OAC). (Level of Evidence: Grade C)"

Primary PCI

Class I

"1. In the setting of STEMI, radial access for primary PCI is the best option to avoid procedural bleeding depending on operator expertise and preference. (Level of Evidence: A)"

"2. Long-term antithrombotic therapy (beyond 12 months) is recommended with OAC in all patients. (Level of Evidence: B)"

Class III

"1. The routine use of ticagrelor or prasugrel in combination with OAC is not recommended. (Level of Evidence: B)"

Class IIa

"1. In patients with STEMI and atrial fibrillation at low risk of bleeding (HAS-BLED 0–2), the initial use of triple therapy (OAC, aspirin, and clopidogrel) should be considered for 6 months following PCI irrespective of stent type; this should be followed by long-term therapy (up to 12 months) with OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day). (Level of Evidence: Grade C)"

"2. In patients with STEMI and atrial fibrillation at high risk of bleeding (HAS-BLED ≥3), the initial use of triple therapy (OAC, aspirin, and clopidogrel) should be considered for 4 weeks following PCI irrespective of stent type; this should be followed by long-term therapy (up to 12 months) with OAC and clopidogrel 75 mg/day (or alternatively, aspirin 75–100 mg/day). (Level of Evidence: Grade C)"

Class IIb

"1. In the acute setting, a patient with atrial fibrillation and STEMI may be treated with primary PCI, aspirin, clopidogrel, and heparin (UFH) or bivalirudin, while GP IIb/IIIa inhibitors in bailout situations might be useful in some cases. Given the risk of bleeding with such combination antithrombotic therapies, it may sometimes be prudent to temporarily stop OAC therapy. Regular or even ‘routine’ use of GP IIb/IIIa inhibitors is discouraged, as are the novel P2Y12 inhibitors. (Level of Evidence: Grade B)"

"2. In selected patients with STEMI and a CHA2DS2-VASc score ≥2 at low risk of bleeding (HAS-BLED 0–2), continuation of triple therapy or dual antiplatelet therapy consisting of OAC (i.e. whether NOAC or a vitamin K antagonist) and clopidogrel 75 mg/day may be considered between 6 and 12 months. (Level of Evidence: Grade C)"

"3. As an alternative to the initial triple therapy in selected patients at high risk of bleeding (e.g. HAS-BLED ≥3) and low risk of stent thrombosis/recurrent ischaemic events, dual therapy consisting of OAC and clopidogrel 75 mg/ day may be considered. (Level of Evidence: Grade B)"

"4. Combination OAC plus single antiplatelet therapy (preferably clopidogrel 75 mg/day, or as an alternative, aspirin 75– 100 mg/day) may sometimes be continued in very selected cases, e.g. stenting of the left main, proximal bifurcation, recurrent MIs, etc. (Level of Evidence: Grade B)"

"5. The use of ticagrelor or prasugrel in combination with OAC may only be considered under very circumstances (e.g. definite stent thrombosis while on clopidogrel, aspirin, and OAC). (Level of Evidence: Grade C)"

Application to General Anticoagulated Patients Who May or May Not Have AF

Class III

"1. NOACs must not be used in patients with mechanical heart valves or valvular atrial fibrillation. (Level of Evidence: B)"

Class IIa

"1. Where patients have atrial fibrillation and a prosthetic mechanical heart valve, such patients would be at substantial risk of thromboembolism and/or prosthetic valve thrombosis during interruption of anticoagulation using a vitamin K antagonist. These patients should undergo percutaneous procedures during anticoagulation with vitamin K antagonist with the lowest possible median INR within the therapeutic range based on risk factors and prosthesis thrombogenicity. (Level of Evidence: Grade B)"

"2. Patients with recent (3–6 months) or recurrent venous thromboembolism are at risk of recurrent events if anticoagulation is interrupted. Arterial access via the radial route should be preferred in such patients, especially during therapeutic anticoagulation (vitamin K antagonist, with INR 2–3; or NOACs) depending on operator expertise. (Level of Evidence: Grade C)"

"3. In patients with stable vascular disease (e.g. with no acute ischaemic events or PCI/stent procedure in the preceding 1 year), OAC monotherapy (well-controlled vitamin K antagonist or a NOAC) should be used, and concomitant antiplatelet therapy should not be prescribed on a routine basis. (Level of Evidence: Grade B)"

Class IIb

"1. Combination of OAC plus single antiplatelet therapy (preferably clopidogrel 75 mg/day, or as an alternative, aspirin 75–100 mg/day) may be sometimes continued in very selected cases, e.g. stenting of the left main, proximal left anterior descending, proximal bifurcation, recurrent MIs, etc. (Level of Evidence: Grade B)"

2012 Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Patients With AF and Stable Coronary Artery Disease

Class II

"1. For patients with atrial fibrillation and stable coronary artery disease (eg, no acute coronary syndrome within the previous year) and who choose oral anticoagulation, we suggest adjusted-dose vitamin K antagonist therapy alone (target INR range, 2.0-3.0) rather than the combination of adjusted-dose vitamin K antagonist therapy and aspirin. (Level of Evidence: Grade C)"

Patients With AF and Placement of an Intracoronary Stent (With or Without Recent ACS)

Class II

"1. For patients with atrial fibrillation at high risk of stroke (eg, CHADS2 score of 2 or greater) during the first month after placement of a bare metal stent or the first 3 to 6 months after placement of a drug-eluting stent, we suggest triple therapy (eg, vitamin K antagonist therapy, aspirin, and clopidogrel) rather than dual antiplatelet therapy (eg, aspirin and clopidogrel). After this initial period of triple therapy, we suggest a vitamin K antagonist (INR 2.0-3.0) plus a single antiplatelet drug rather than vitamin K antagonist alone. At 12 months after intracoronary stent placement, antithrombotic therapy is suggested as for patients with atrial fibrillation and stable coronary artery disease. (Level of Evidence: Grade C)"

"2. For patients with atrial fibrillation at low to intermediate risk of stroke (eg, CHADS2 score of 0 or 1) during the first 12 months after placement of an intracoronary stent (bare metal stent or drug eluting stent), we suggest dual antiplatelet therapy rather than triple therapy. At 12 months after intracoronary stent placement, antithrombotic therapy is suggested as for patients with atrial fibrillation and stable coronary artery disease. (Level of Evidence: Grade C)"

Patients With AF and ACS Who Do Not Undergo Intracoronary Stent Placement

Class II

"1. For patients with atrial fibrillation at intermediate to high risk of stroke (eg, CHADS2 score of 1 or greater) who experience an acute coronary syndrome and do not undergo intracoronary stent placement, we suggest for the first 12 months, adjusted-dose vitamin K antagonist therapy (INR 2.0-3.0) plus single antiplatelet therapy rather than dual antiplatelet therapy (eg, aspirin and clopidogrel) or triple therapy (eg, warfarin, aspirin, and clopidogrel). After the first 12 months, antithrombotic therapy is suggested as for patients with atrial fibrillation and stable coronary artery disease. (Level of Evidence: Grade C)"

"2. For patients with atrial fibrillation at low risk of stroke (eg, CHADS2 score of 0), we suggest dual antiplatelet therapy (eg, aspirin and clopidogrel) rather than adjusted-dose vitamin K antagonist therapy (INR 2.0-3.0) plus single antiplatelet therapy or triple therapy (eg, warfarin, aspirin, and clopidogrel). After the first 12 months, antithrombotic therapy is suggested as for patients with atrial fibrillation and stable coronary artery disease. (Level of Evidence: Grade C)"

2010 Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC)

Recommendations for antithrombotic therapy in AF and ACS/PCI

Class IIa

"1.Following elective PCI in patients with AF with stable coronary artery disease, BMS should be considered, and drug-eluting stents avoided or strictly limited to those clinical and/or anatomical situations (e.g. long lesions, small vessels, diabetes, etc.), where a significant benefit is expected when compared with BMS. (Level of Evidence: Grade C)"

"2.Following elective PCI, triple therapy (VKA, aspirin, clopidogrel) should be considered in the short term, followed by more long-term therapy (up to 1 year) with VKA plus clopidogrel 75 mg daily (or, alternatively, aspirin 75–100 mg daily, plus gastric protection with PPIs, H2 antagonists, or antacids). (Level of Evidence: Grade C)"

"3. Following elective PCI, clopidogrel should be considered in combination with VKA plus aspirin for a minimum of 1 month after implantation of a BMS, but longer with a drug-eluting stent (at least 3 months for a sirolimus-eluting stent and at least 6 months for a paclitaxel-eluting stent); following which VKA and clopidogrel 75 mg daily (or, alternatively, aspirin 75–100 mg daily, plus gastric protection with either PPIs, H2 antagonists, or antacids) should be considered, if required. (Level of Evidence: Grade C)"

"4. Following an ACS with or without PCI in patients with AF, triple therapy (VKA, aspirin, clopidogrel) should be considered in the short term (3–6 months), or longer in selected patients at low bleeding risk, followed by long-term therapy with VKA plus clopidogrel 75 mg daily (or, alternatively, aspirin 75–100 mg daily, plus gastric protection with PPIs, H2 antagonists, or antacids). (Level of Evidence: Grade C)"

"5. In anticoagulated patients at very high risk of thrombo-embolism, uninterrupted therapy with VKA as the preferred strategy and radial access used as the first choice even during therapeutic anticoagulation (INR 2–3). (Level of Evidence: Grade C)"

Class IIa

"1.When VKA is given in combination with clopidogrel or low-dose aspirin, careful regulation of the anticoagulation dose intensity may be considered, with an INR range of 2.0–2.5. (Level of Evidence: Grade C)"

"2.Following revascularization surgery in patients with AF, VKA plus a single antiplatelet drug may be considered in the initial 12 months, but this strategy has not been evaluated thoroughly and is associated with an increased risk of bleeding. (Level of Evidence: Grade C)"

"3.In patients with stable vascular disease (e.g. >1 year, with no acute events), VKA monotherapy may be considered, and concomitant antiplatelet therapy should not be prescribed in the absence of a subsequent cardiovascular event. (Level of Evidence: Grade C)"

References

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