Triple Antithrombotic Therapy in Atrial Fibrillation Patients With an Indication for Oral Anticoagulation Undergoing Percutaneous Coronary Intervention

Atrial fibrillation (AF) is a growing problem, affecting 5.2 million people in the United States in 2010, with a prevalence that is expected to increase to over 12 million by 2030.1,2 The standard of care for stroke prevention in such patients at increased risk, as indicated by a congestive heart failure, hypertension, age ≥75 y (doubled), diabetes mellitus, prior stroke or TIA or thromboembolism (doubled), vascular disease, age 65–74 y, sex category (CHA2DS2-VASc) score3 ≥1, is anticoagulation with a vitamin K antagonist (VKA) or novel oral anticoagulant (NOAC).4 In addition, patients with AF have a high risk of concomitant coronary artery disease (CAD), and when percutaneous coronary intervention (PCI) is required, treatment with aspirin and a platelet P2Y12 receptor inhibitor also becomes indicated.5–7 In such cases, the risk of thromboembolic events and stent thrombosis (ST) after PCI must be weighed against the risk of major bleeding.8–11 Newer, more potent antiplatelet therapy and novel anticoagulants have emerged, thus, making the decision of triple therapy (TT) even more challenging. The optimal antithrombotic therapy for AF patients undergoing PCI is as yet unknown. For many primary care physicians and general cardiologists, the duration, benefits, and bleeding risks of TT in AF patients is unclear.We describe a clinical case of a patient with AF undergoing PCI and discuss medical management for such patients with an emphasis on the recent available data.A 77-year-old woman with permanent AF, diabetes mellitus, dyslipidemia, who was receiving warfarin to prevent stroke presented to the outpatient clinic with progressive chest pain for the past 3 months. She was a former smoker and was carefully taking her medication, which included β-blockers, statins, metformin, and warfarin, with stable international normalized ratio (INR) results. Her ECG …