Is triple antithrombotic therapy a safe option in patients with AF who receive drug-eluting stents?: a review article

Abstract

Background Optimal antithrombotic therapy depicts a challenge to clinicians treating atrial fibrillation (AF) patients who are undergoing percutaneous coronary intervention (PCI). Theoretically, these patients would require a combination therapy of oral anticoagulant and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, known as triple antithrombotic therapy (TAT). However, TAT is known to carry a significant risk of bleeding. The purpose of the present paper is to provide a focused review of the evidence about the safety of TAT as well as to address contemporary directions regarding antithrombotic therapy following PCI in patients with AF who received a drug-eluting stent. Main body Novel oral anticoagulant studies consistently demonstrated a better safety profile when compared to Vitamin K antagonist (warfarin), especially in AF patients who have other indications of DAPT after PCI. Evidence from several studies showed that the use of TAT in AF patients undergoing stent implantation or PCI has no significant clinical benefit with more risk of major bleeding when compared to DAT. Therefore, the current recommendations for AF have taken into account the mounting evidence of antithrombotic treatment after PCI in AF patients, which has caused a major shift away from the TAT strategy toward DAT over time. Conclusions Cardiologists face challenges in determining the best antithrombotic treatment for AF patients after PCI with DES implantation. Growing data suggest that TAT is associated with considerable bleeding and worse safety, without significant effectiveness. Hence, TAT is strictly applied for individuals with significant thrombotic risk and low bleeding risk, and for a limited duration. This paper highlights the safety concerns of TAT and current trends in antithrombotic therapy after PCI in patients with AF and DES.

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients—A Review: Part I—Epidemiology, Risk Factors, and Atherosclerosis-Related Diversities in Elderly Patients

“…Surgical and endovascular interventions should be reserved for emergencies and life-threatening situations. Balanced pharmacotherapy is associated with a reduction in side effects and drug interactions, while careful referral of patients for surgical and endovascular interventions helps to avoid peri-operative complications and those related to post-operative pharmacotherapy (e.g., antiplatelet and antithrombotic treatment) [ 70 , 71 , 72 ]. There is still uncertainty as to whether some pharmacological interventions should not be guided individually.…”

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients—A Review PART II—Pharmacological Approach for Management of Elderly Patients with Peripheral Atherosclerotic Lesions outside Coronary Territory

“…When full anticoagulation is indicated, the addition of drugs from other anticoagulant classes is not recommended, except in situations directly related to peripheral artery revascularization, especially in combination with stent implantation. Triple anticoagulant therapy should be avoided, especially in patients over 70 years of age [ 112 , 113 ].…”