Antithrombotic Strategies in Atrial Fibrillation and Angioplasty

What is the most appropriate antithrombotic strategy for a patient with atrial fibrillation and coronary artery disease, particularly when admitted with acute coronary syndrome or undergoing coronary angioplasty? This is a question whose answer is still in the works and that literature is addressing dynamically. Whatever we read yesterday may already be out of date today, but the problem remains the same: proper balance between ischemic risk and bleeding risk.

terapia antitrombótica triple

Our information for today (tomorrow, really, because this work is yet to be published) is that the combination of vitamin K antagonists and dual antiplatelet therapy must be avoided at any cost, while the strategy of choice should be anticoagulation through a direct inhibitor plus a P2Y12 inhibitor without aspirin. Such information derives from this meta-analysis that assessed the safety and efficacy of multiple antithrombotic/anticoagulant strategies in over 10,000 patients from 4 randomized studies (WOEST, PIONEER, AF-PCI, RE-DUAL PCI, and AUGUSTUS).

The prevalence of acute coronary syndromes varied among works from 28% to 61%, and the mean age ranged from 70 to 72 years old. Most patients were at high risk for both thromboembolic and bleeding events.

Compared with a regimen of vitamin K inhibitor plus dual antiplatelet therapy, the odds ratio (OR) for major bleeding was 0.58 for vitamin K inhibitor plus P2Y12 inhibitor (without aspirin), 0.49 for direct inhibitor plus P2Y12 inhibitor only, and 0.70 for a direct inhibitor plus conventional dual antiplatelet therapy.


Read also: 500 Years after What Might Have Been the Start of Modern Cardiology.


No significant differences were observed after conducting the same scheme comparisons, but focusing on ischemic events.

Conclusion

Among all possible schemes, an anticoagulation regime with a direct inhibitor plus a P2Y12 inhibitor without aspirin is associated with less bleeding without a spike in thrombotic events.

The combination of vitamin K inhibitor plus dual antiplatelet therapy should be avoided.

Original Title: Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. A Network Meta-analysis of Randomized Controlled Trials.

Reference: Renato D. Lopes et al. JAMA Cardiol. 2019 Jun 19. [Epub ahead of print].


Subscribe to our weekly newsletter

Get the latest scientific articles on interventional cardiology

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.

More articles by this author

STEACS and the Use of Bivalirudin vs. Heparin: In Search of BRIGHT-4 Outcomes

Various studies and registries have previously shown the impact of post-percutaneous coronary intervention (PCI) complications on the survival of patients with ST-segment elevation acute...

TAVR and Atrial Fibrillation: What Anticoagulants Should We Use?

The prevalence of atrial fibrillation (AF) in TAVR patients ranges from 15 to 30%, depending on series. This arrhythmia has been associated to higher...

Ultrathin vs Thin-Strut Stents in PCI Patients at High Bleeding Risk

Several in vivo studies have shown that ultrathin stents present lower thrombogenic risk vs. thin-strut stents, which reflects in lower rates of target lesion...

Should We Withdraw Anticoagulation Before TAVR?

Approximately one-third of patients undergoing transcatheter aortic valve replacement (TAVR) have atrial fibrillation and are on oral anticoagulant (OAC) therapy. This creates a complex...

LEAVE A REPLY

Please enter your comment!
Please enter your name here

Related Articles

SOLACI Sessionsspot_img

Recent Articles

TCT 2024 | FAVOR III EUROPA

The study FAVOR III EUROPA, a randomized trial, included 2,000 patients with chronic coronary syndrome, or stabilized acute coronary syndrome, and intermediate lesions. 1,008...

TCT 2024 | TRISCEND II

This randomized study included 400 patients; 267 were treated with EVOQUE valve and 133 with optimal medical treatment (OMT). After one-year follow-up, there were no...

TCT 2024 – ACCESS-TAVI: Comparing Percutaneous Access Closure Strategies After TAVI

Vascular access complications following transcatheter aortic valve implantation (TAVI) remain common. However, few studies compare vascular access closure methods.  Based on the CHOICE-CLOSURE and MASH...