Evolving paradigms in antithrombotic therapy for anticoagulated patients undergoing coronary stenting

Abstract

A sizable proportion of coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) with stent implantation have an indication for treatment with oral anticoagulant therapy (OAC). The coexistence of atrial fibrillation (AF) and the need for PCI expose patients to a higher risk of developing thrombotic complications, and a multitargeted antithrombotic treatment strategy, addressing both platelet- and coagulation-mediated triggering mechanisms of thrombosis, is necessary for ensuring full protection from ischemic hazards. The increased bleeding risk identified with triple antithrombotic therapy has driven the search for alternative treatment modalities and pharmacological combination strategies aimed at achieving an optimal balance between safety and efficacy in this complex clinical scenario. Over a short time period, the paradigms surrounding the management of patients undergoing PCI who require OAC have substantially evolved. In this review, we summarize and critically evaluate the results of recent randomized clinical trials investigating the pharmacological management of patients who, in addition to antiplatelet therapy, have an indication for OAC treatment before or at the time of a PCI procedure.

Evolving Antithrombotic Treatment Patterns for Patients With Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome or Underwent Percutaneous Coronary Intervention in China: A Cross-Sectional Study

“…Therefore, combined therapy is needed in patients with NVAF having ACS/PCI. But combined antithrombotic treatment is related to an increased risk of bleeding at the same time (10). The concomitant presence of these conditions represents a challenge in clinical practice.…”

Net clinical benefit of antithrombotic therapy for atrial fibrillation patients with stable coronary artery disease

“…Considering the results of previous studies and the trade-off of ischemic risk and bleeding risk after PCI ( 8 – 10 , 24 ), the clinical benefits of OAC monotherapy over OAC plus SAPT may differ depending on how long it has elapsed since a year from PCI. However, there have been no studies attempting to analyze whether the benefit of treatment varies with the elapsed time after PCI in RCTs or observational studies.…”

“…Although the AFIRE trial demonstrated that rivaroxaban monotherapy is superior to rivaroxaban plus SAPT in primary safety outcomes, there have been conflicting data regarding the comparative effectiveness and safety of OAC monotherapy vs. OAC plus SAPT according to the time from index PCI to study enrollment ( 8 , 9 ). Considering the temporal dynamic of the risk of stent thrombosis after PCI and thromboembolic risk in patients with AF ( 10 ), we can hypothesize that the efficacy and safety of antithrombotic treatment strategies can temporally vary. However, it has not been studied whether the net clinical benefit of the antithrombotic treatment options differs depending on the elapsed time from the index PCI.…”

Changes of antithrombotic prescription in atrial fibrillation patients with acute coronary syndrome or percutaneous coronary intervention and the subsequent impact on long-term outcomes: a longitudinal cohort study

“…However, the strategy of optimal antithrombotic therapy in patients with AF and concomitant CAD remains challenging. [ 4 , 5 ] Thromboembolism as a result of AF has a stasis and fibrin drive, whereas atherothrombosis is mainly driven by endothelial plaque rupture, platelet aggregation, and even partially thrombin generation. [ 6 ] Clinically, dual antiplatelet therapy (DAPT) with a P2Y 12 inhibitor plus aspirin were recommended in patients with acute coronary syndrome (ACS) or who underwent percutaneous coronary intervention (PCI) with implantation of stent.…”