Antithrombotic Therapy During and After Percutaneous Coronary Intervention in Patients With Atrial Fibrillation

A 64-year-old man has permanent atrial fibrillation and chronic hypertension. He has been treated with atenolol 50 mg daily, lisinopril 10 mg daily, and warfarin for the last 4 years. Otherwise, he is in good shape and employed full-time as a technical director of a large shipbuilding company. At a routine visit about 1 year ago, he complained of chest pain and dyspnea on exertion. An exercise myocardial scintigraphy showed a reversible defect in the anteroseptal region with a normal left ventricular ejection fraction. Simvastatin 40 mg daily was added to his medication, and the dose of atenolol was increased to 100 mg daily. His symptoms persisted and increased over the last several weeks. Coronary angiography showed single-vessel disease of the proximal left anterior descending coronary artery. The heart team decided that the best option would be percutaneous coronary intervention with a drug-eluting stent. During this procedure, the international normalized ratio was tapered to 2.0. The procedure was successful, and he was put on additional aspirin and clopidogrel.The patient had an uneventful recovery and was free of symptoms. He was seen 3 months after the procedure by his attending cardiologist, who stopped aspirin. One year after the procedure, the patient came for his follow-up visit, and his clopidogrel was discontinued. He remains on atenolol, lisinopril, simvastatin, and warfarin and is doing well.Dual antiplatelet therapy has become the cornerstone of the treatment of patients undergoing coronary stenting and of those with acute coronary syndromes with or without stent implantation. Although there is consensus about the indication for dual antiplatelet therapy, little evidence exists about the optimal duration of therapy. In patients surviving non–ST-segment–elevation acute coronary syndromes, 1 year of treatment is advised. …