Management of Antiplatelet and Anticoagulant Therapy in Patients With Atrial Fibrillation in the Setting of Acute Coronary Syndromes or Percutaneous Coronary Interventions

Atrial fibrillation (AF), the most common cardiac arrhythmia, occurs in 1% to 2% of the general population, with a prevalence varying from 0.5% in subjects 40 to 50 years old to 5% to 15% in the elderly who are >80 years old.1–3 Stroke is the most feared complication of AF, resulting in death or disabling symptoms in a vast proportion of cases.4 In the Framingham study, the age-adjusted incidence of stroke was 5-fold higher in subjects with AF, and the attributable risk raised from 1.5% at 50 to 59 years to 23.5% at 80 to 89 years.5Chronic oral anticoagulation (OAC) therapy is the mainstay of stroke prevention in patients with AF at high risk for cardioembolic sequelae; ≈70% to 80% of all patients with AF have an indication for OAC, and coronary artery disease coexists in 20% to 30% of them.6,7 With an estimated prevalence of AF in 1% to 2% of the population, it may be projected that ≈1 to 2 million patients on OAC in both the United States and Europe are candidates for coronary revascularization, often in the form of percutaneous coronary interventions (PCI). Patients undergoing PCI, as well as those who present with an acute coronary syndrome (ACS), also require dual antiplatelet therapy (DAPT), usually aspirin in combination with a platelet adenosine diphosphate P2Y12 receptor antagonist, with the goal of reducing the risk of ischemic recurrences, including stent thrombosis.8 However, the efficacy and safety of combining OAC with DAPT (triple antithrombotic therapy) in these patients is a topic of debate. In fact, although this combination can potentially prevent both thromboembolism and atherothrombotic events, it is also associated with an increased risk of severe bleeding. In a large nationwide registry of 40 812 patients hospitalized with …