Triple Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Stents

Case presentation: A 76-year-old man with rate-controlled atrial fibrillation (AF), diabetes mellitus, and prior stroke who is receiving warfarin to prevent recurrent stroke presents to the emergency department with chest pain, elevated serum troponin, and an ECG that demonstrates ST depression in the precordial leads. Cardiac catheterization reveals an ulcerated plaque and partially obstructive thrombus in the left circumflex coronary artery. Percutaneous coronary intervention is performed with placement of 2 bare-metal stents. What is the optimal antithrombotic therapy? What is the optimal antithrombotic therapy if the patient receives drug-eluting stents instead of bare-metal stents?Meta-analyses of randomized controlled trials in patients with nonvalvular AF indicate that oral vitamin K antagonist (VKA) therapy reduces the risk of stroke or systemic embolism by 64% compared with placebo and by 39% compared with aspirin.1,2 In the ACTIVE trials (Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events), warfarin reduced the risk of stroke or systemic embolism by 42% compared with dual-antiplatelet therapy with the combination of aspirin and clopidogrel,3 whereas dual-antiplatelet therapy reduced the risk by 28% compared with aspirin alone.4 Recently, the RE-LY trial (Randomized Evaluation of Long-term anticoagulant therapY) showed that compared with warfarin the oral direct thrombin inhibitor, dabigatran etexilate given at a dose of 150 mg twice daily reduces stroke with less intracranial bleeding, and dabigatran 110 mg twice daily has similar efficacy with less bleeding.5 Dabigatran etexilate is not yet approved for stroke prevention in AF.The 2006 American College of Cardiology/American Heart Association/European Society of Cardiology and the 2008 American College of Chest Physicians guidelines both recommend stratification of patients with AF according to their risk of stroke to guide the choice of antithrombotic therapy. The guidelines recommend VKA therapy for patients with a CHADS2 score >1, either aspirin or …