Concomitant Use of Antiplatelets and Anticoagulants in Patients with Coronary Heart Disease and Atrial Fibrillation: What Do Recent Clinical Trials Teach Us?

Abstract

We review clinical trials and current guidelines for antiplatelet and anticoagulant therapy in CHD and AF. Aspirin and P2Y inhibitors are the mainstay of antiplatelet therapy. Vitamin K antagonists (VKAs) are the most commonly used anticoagulant, although the use of non-VKA oral anticoagulants (NOACs) in patients with AF is increasing. Recent studies provide guidance on how to address antithrombotic therapies in patients with concomitant CHD and AF. To date, we have evidence that in patients with AF who undergo percutaneous coronary intervention (PCI), clopidogrel with VKA may be used safely without aspirin. Also, low-dose rivaroxaban in combination with either clopidogrel only or DAPT is as effective as the traditional regimen of triple therapy with VKA and DAPT with lower bleeding risk. Dabigatran with a P2Y inhibitor was also found to be safe with less bleeding compared to triple therapy with VKA and DAPT. Use of a single antiplatelet agent with anticoagulation has become a viable choice in patients with CHD and AF, but more clinical trial data is needed to confirm therapy and duration regimens.

Temporal trends in prevalence and antithrombotic treatment among Asians with atrial fibrillation undergoing percutaneous coronary intervention: A nationwide Korean population-based study

“…Therefore, patients with AF undergoing PCI and stent implantation are recommended to receive combination antithrombotic therapy including OACs and antiplatelets. However, there are concerns about the clinical benefit of intensive combination antithrombotic therapy, as it increases the risk of fatal bleeding, which would offset the benefit in reducing the ischemic risk [6–9]. As non-vitamin K antagonist oral anticoagulants (NOACs) had shown a safety benefit in patients with AF compared with conventional vitamin K antagonists (VKAs) [10,11], recent clinical trials have investigated the clinical benefit of dual antithrombotic therapy combining NOAC and P2Y 12 antagonists (mostly clopidogrel) as an alternative to triple therapy after PCI in patients with AF [12–15].…”

Dual Anticoagulant/Antiplatelet Activity of Polyphenolic Grape Seeds Extract

“…Antiplatelet and anticoagulant drugs have been the major players in their clinical setting [1,2]. Although their efficacy is well established, their deleterious, life-threatening side-effects have also been well documented [3,4] which has prompted investigations into natural alternatives. An exploratory trial to identify new anticoagulants and anti-platelets sourced from medicinal plants is worthwhile.…”

New oral anticoagulants combined with antiplatelet therapy in the treatment of coronary heart disease: an updated meta-analysis

“…This result is also likely to be explained by the fact that most of those patients were treated with single antiplatelet therapy combined with NOACs. Thus, the use of a single antiplatelet agent with NOACs may be a more viable choice in patients with CHD, but more clinical trial data is needed to con rm individualized therapy regimens [34][35][36][37].…”