scholarly journals DAPT plus anticoagulant therapy: The difficult coexistence post-ACS in older patients with atrial fibrillation

2018 ◽  
Vol 88 (2) ◽  
Author(s):  
Mauro Di Bari ◽  
Alessandra Pratesi ◽  
Francesca M. Nigro ◽  
Irene Marozzi ◽  
Stefano Fumagalli
Keyword(s):  
Atrial Fibrillation ◽  
Triple Therapy ◽  
Older Patients ◽  
Randomized Clinical Trials ◽  
Treatment Guidelines ◽  
Coronary Intervention ◽  
Current Treatment ◽  
Difficult Problem ◽  
Coronary Syndrome ◽  
Artery Disease

Atrial fibrillation (AF) and coronary artery disease requiring percutaneous coronary intervention (PCI) and stenting often coexist in older patients. This poses the difficult problem of concurrent anticoagulant and double antiplatelet therapy (triple therapy). Current treatment guidelines do recommend triple therapy, especially in the course of acute coronary syndrome (ACS), with limitations due to an excessive risk of bleeding associated with this therapeutic regimen. This review summarizes randomized clinical trials and observational studies that compared triple therapy with a variety of different therapeutic options. Although the available evidence is not completely satisfactory and other studies are urgently needed, alternative regimens to triple therapy in AF patients undergoing PCI and stenting are promising, at least in terms of safety.

Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: Where Are We Now?

2018 ◽  
Vol 52 (9) ◽  
pp. 884-897 ◽  
Author(s):  
Ryan G. D’Angelo ◽  
Thaddeus McGiness ◽  
Laura H. Waite
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Triple Therapy ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Low Risk ◽  
Current Evidence ◽  
Patient Specific ◽  
Coronary Syndrome ◽  
Percutaneous Coronary

Objective: To synthesize the literature and provide guidance to practitioners regarding double therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) requiring percutaneous coronary intervention (PCI). Data Sources: PubMed and MEDLINE (January 2000 to February 2018) were searched using the following terms: atrial fibrillation, myocardial infarction, acute coronary syndrome, percutaneous coronary intervention, anticoagulation, dual-antiplatelet therapy, clopidogrel, aspirin, ticagrelor, prasugrel, and triple therapy. Study Selection and Data Extraction: The results included randomized and nonrandomized clinical trials and meta-analyses. Each study was reported based on study design, population, intervention, comparator, and key cardiovascular (CV) and bleeding outcomes. Data Synthesis: A total of 15 studies were included in the review. The majority of studies evaluating DT and TT utilized clopidogrel and warfarin as components of the regimen, although there are emerging data with newer agents. Evidence purporting DT regimens to be equally effective in preventing CV events and improved safety profiles compared with TT regimens included populations with relatively low risk for recurrent CV events, and many of these studies were observational in nature. Overall, current evidence as well as American and European guidelines support the use of TT in patients with AF who require PCI for the least possible amount of time, depending on patient-specific factors involving bleeding and thrombosis. Conclusions: In the majority of patients with AF who require PCI, TT should be used for the shortest period of time possible. DT regimens may be used in patients requiring PCI who have low risk for thrombosis and/or high bleeding risk.

scholarly journals Safety and efficacy of double vs. triple antithrombotic therapy in patients with atrial fibrillation with or without acute coronary syndrome undergoing percutaneous coronary intervention: a collaborative meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials

2020 ◽  
Author(s):  
Giuseppe Gargiulo ◽  
Christopher P Cannon ◽  
Charles Michael Gibson ◽  
Andreas Goette ◽  
Renato D Lopes ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Coronary Intervention ◽  
Vitamin K Antagonist ◽  
Safety And Efficacy ◽  
Coronary Syndrome ◽  
Percutaneous Coronary ◽  
Triple Antithrombotic Therapy

Abstract Aims Safety and efficacy of antithrombotic regimens in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) may differ based on clinical presentation. We sought to compare double vs. triple antithrombotic therapy (DAT vs. TAT) in AF patients with or without acute coronary syndrome (ACS) undergoing PCI. Methods and results A systematic review and meta-analysis was performed using PubMed to search for non-vitamin K antagonist oral anticoagulant (NOAC)-based randomized clinical trials. Data on subgroups of ACS or elective PCI were obtained by published reports or trial investigators. A total of 10 193 patients from four NOAC trials were analysed, of whom 5675 presenting with ACS (DAT = 3063 vs. TAT = 2612) and 4518 with stable coronary artery disease (SCAD; DAT = 2421 vs. TAT = 2097). The primary safety endpoint of ISTH major bleeding or clinically relevant non-major bleeding was reduced with DAT compared with TAT in both ACS (12.2% vs. 19.4%; RR 0.63, 95% CI 0.56–0.71; P < 0.0001; I2 = 0%) and SCAD (14.6% vs. 22.0%; RR 0.68, 95% CI 0.55–0.85; P = 0.0008; I2 = 66%), without interaction (P-int = 0.54). Findings were consistent for secondary bleeding endpoints, including intra-cranial haemorrhage. In both subgroups, there was no difference between DAT and TAT for all-cause death, major adverse cardiovascular events, or stroke. Myocardial infarction and stent thrombosis were numerically higher with DAT vs. TAT consistently in ACS and SCAD (P-int = 0.60 and 0.86, respectively). Findings were confirmed by multiple sensitivity analyses, including a separate analysis on dabigatran regimens and a restriction to PCI population. Conclusions DAT, compared with TAT, is associated with lower bleeding risks, including intra-cranial haemorrhage, and a small non-significant excess of cardiac ischaemic events in both patients with or without ACS.

scholarly journals Ticagrelor: A safe option as part of triple therapy?

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Mohammad Umar Farooq
Keyword(s):  
Atrial Fibrillation ◽  
Coronary Artery Disease ◽  
Triple Therapy ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agent ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Percutaneous Coronary ◽  
Artery Disease ◽  
Ischemic Events

Patients with atrial fibrillation who have concurrent coronary artery disease requiring percutaneous coronary intervention are subsequently prescribed dual antiplatelet therapy and anticoagulation resulting in triple therapy (TT). Ticagrelor, a reversibly binding P2Y12 antiplatelet agent, has shown superiority to clopidogrel in prevention of ischemic events and death, but is also associated with a small increase in the incidence of intracranial bleeding. This bleeding risk may be enhanced in the setting of TT. The objective of this report is to describe a case of a 70-year-old male prescribed TT with ticagrelor and to review the current literature on the safety of ticagrelor as a part of TT.

Thrombin Generation in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Cardiology ◽  
2021 ◽  
pp. 1-6
Author(s):  
Chen Gurevitz ◽  
Alon Eisen ◽  
Eli Lev ◽  
Osnat Itzhaki Ben Zadok ◽  
Leor Perl ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Triple Therapy ◽  
Thrombin Generation ◽  
Dual Therapy ◽  
Coronary Intervention ◽  
Withdrawal Time ◽  
Coronary Syndrome ◽  
Percutaneous Coronary ◽  
Significant Difference

<b><i>Background:</i></b> The optimal antithrombotic treatment for patients with atrial fibrillation (AF) that undergo percutaneous coronary intervention (PCI) is controversial. Dual therapy (clopidogrel and a direct oral anticoagulant [DOAC]) is safer than triple therapy (warfarin, aspirin, and clopidogrel), while efficacy is unclear. We aimed to evaluate thrombin generation (TG) under dual and triple therapy. <b><i>Methods:</i></b> A noninterventional prospective trial in patients with AF undergoing PCI. Patients received 4 weeks of triple therapy with aspirin, clopidogrel, and a DOAC followed by aspirin withdrawal. TG was measured in platelet-rich plasma (PRP) and platelet-poor plasma (PPP) at 3 <i>five to 21</i> points, day 1 after PCI (TIME 0), 4 weeks after PCI (TIME 1), and 2 weeks after aspirin withdrawal (TIME 2). <b><i>Results:</i></b> Twenty-three patients (18 men, median age 78 years, 83% with acute coronary syndrome) were included. Endogenous thrombin potential (ETP) in PPP was high at TIME 0 compared with TIME 1 (ETP 3,178 ± 248 nM vs. 2,378 ± 222 nM, <i>p</i> = 0.005). These results remained consistent when measured in PRP. No significant difference in ETP was found before (TIME 1) and after aspirin withdrawal (TIME 2) although few patients had high ETP levels after stopping aspirin. <b><i>Conclusions:</i></b> TG potential is high immediately after PCI and decreases 4 weeks after PCI in patients receiving triple therapy. TG remains constant after aspirin withdrawal in most patients, suggesting that after 1 month the antithrombotic effect of dual therapy may be similar to triple therapy.

scholarly journals Modern strategy of antithrombotic therapy in patients with coronary artery disease and atrial fibrillation after percutaneous coronary intervention

2019 ◽  
pp. 137-147
Author(s):  
Yu. A. Karpov
Keyword(s):  
Atrial Fibrillation ◽  
Coronary Artery Disease ◽  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Coronary Intervention ◽  
Coronary Syndrome ◽  
Percutaneous Coronary ◽  
Artery Disease

Reducing of cardiovascular risk, morbidity and mortality is considered as one of the main aims of modern cardiology, which should help increase life expectancy. Oral anticoagulants are the basis for the cardioembolic stroke prevention in patients with atrial fibrillation, which is common in patients with coronary artery disease. According to statistics, about a quarter of patients with atrial fibrillation have to perform percutaneous coronary intervention at some point in their life. This is due to stable angina or acute coronary syndrome, which is accompanied by difficulties with antithrombotic therapy. This article discusses the main clinical data and recommendations on the optimal use of combination antithrombotic therapy in patients after percutaneous coronary intervention.

scholarly journals Possibility of using dabigatran in patients with atrial fibrillation and acute coronary syndrome and PCI

2019 ◽  
pp. 30-35
Author(s):  
A. D. Erlich
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Triple Therapy ◽  
Oral Anticoagulants ◽  
Dual Therapy ◽  
Clinical Problem ◽  
Coronary Intervention ◽  
Bleeding Complications ◽  
P2y12 Inhibitor ◽  
Coronary Syndrome

This article is devoted to the problem of combined antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) due to acute coronary syndrome (ACS). Traditionally, these patients require an oral anticoagulant (OAC) to prevent stroke and dual anti-platelet therapy (DAT) to prevent coronary complications. The necessity of combining various antithrombotic drugs, since this greatly increases the risk of bleeding is becoming an increasing relevant clinical problem. The prolonged triple therapy in the form of a combination of OAC and DAT does not bring additional benefit to the patients, but, on the contrary, may be potentially dangerous. Currently, the possibility of using several new oral anticoagulants (NOAC) in patients with AF and ACS/PCI in the form of dual therapy has been proven: combination of OAC and p2Y12 inhibitor. The article focuses on the RE-DUAL PCI study, in which the use of dabigatran at both doses permitted in AF (150 mg twice daily and 110 mg twice daily) in combination with the p2Y12 inhibitor was associated with fewer bleeding complications than during the triple therapy in the form of OAK + DAT.The article presents a clinical case of the possibility of management of a patient with AF and ACS under the modern clinical guidelines, as well as an overview of current guidelines for the use of OAC and DAT in patients with AF undergoing PCI. 

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