Acute Coronary Syndrome in Patients With Atrial Fibrillation

Dual antiplatelet therapy is the recommended treatment for all patients with an acute coronary syndrome treated or not treated with an invasive procedure.1–4 Several trials testing clopidogrel5–7 or new antiplatelet agents8,9 clearly showed that the addition of a thyenopiridine to aspirin is associated with a significant improvement of patients' outcomes. Furthermore, even in the case of elective percutaneous coronary procedures, the use of dual antiplatelet therapy is recommended for a medium-long period of time after the procedure.2,4,10Article see p 1185A similar level of good evidence is available for the prevention of ischemic stroke and peripheral thromboembolic events in patients with atrial fibrillation.11,12 In this clinical condition, appropriate use of vitamin K antagonists (VKAs) is associated with a significant reduction of thromboembolic events, in particular ischemic stroke.13 Specifically, in patients with nonvalvular atrial fibrillation, when the risk of stroke is relevantly high (CHA2DS2-VASc ≥2)14 and the risk of bleeding is acceptable (HAS-BLED <3),15 a favorable risk/benefit profile of VKAs, at a dosage that maintains the international normalized ratio between 2 and 3, has been clearly demonstrated.The problem is when these clinical conditions coexist, ie, when a patient with nonvalvular atrial fibrillation, treated appropriately with VKAs, needs …