Triple Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI: a Fading Role

Abstract

Triple antithrombotic therapy (TAT), consisting of aspirin, a P2Y receptor antagonist and oral anticoagulant (OAC) medication has been considered as an 'unavoidable' strategy for a 1-12 months for atrial fibrillation (AF) patients post acute coronary syndrome or percutaneous coronary angioplasty with stenting. However, TAT has rather poorly been adopted in real life practice, mainly because of an accompanying increased bleeding potential and lack of definitive results of randomized clinical trials. Several registries, meta-analyses and small randomized trials have so far provided the base of guidelines recommendations. Furthermore, in the recently published Open-Label, Randomized, Controlled, Multicenter Study Exploring Two Treatment Strategies of Rivaroxaban and a Dose-Adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects with Atrial Fibrillation who Undergo Percutaneous Coronary Intervention (PIONEER AF-PCI) trial involving 2124 patients, the primary safety endpoint of clinically significant bleeding was significantly reduced in the rivaroxaban low dose (15 mg daily) plus single P2Y receptor antagonist arm compared to TAT, with no difference in the secondary efficacy endpoint. Despite several limitations of the PIONEER AF-PCI trial, it appears that among patients who omit aspirin, there may be equivalent ischemic protection with dual therapy and no disadvantage for additional risk of thrombotic events.

Ticagrelor or prasugrel vs. clopidogrel in combination with anticoagulation for treatment of acute coronary syndrome in patients with atrial fibrillation

“…Regarding patients with AF and CAD, it's often challenging to find the optimal balance between the risk for ischemic and hemorrhagic complications in patients requiring both antiplatelet therapy and OAC with a vitamin K antagonist (VKA) or direct oral anticoagulants (DOACs) (6,7).…”

The Management of Combined Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Particularly Complex Challenge, Especially in the Elderly

“…Atrial fibrillation represents the most common arrhythmia, whose prevalence significantly increases with age ( Wilke et al, 2013 ); its incidence is also rapidly growing outlining a global epidemic with tremendous burden of disability and mortality worldwide ( Chugh et al, 2014 ). The incidence of CAD in patients with AF is very high ( Kralev et al, 2011 ) and it is estimated that up to 7% of patients undergoing PCI for CAD suffer of AF or have another indication for OAC ( Alexopoulos et al, 2017 ). Furthermore, AF represents a frequent complication in patients with acute myocardial infarction (AMI) ( Ibanez et al, 2017 ), contributing to worsening prognosis, whereas advanced age and heart failure constitute the main predictors for the onset of this arrhythmia in AMI patients ( Schmitt et al, 2009 ).…”

“…The same investigation group has afterwards published a post hoc analysis to report reduced risk of all-cause mortality or recurrent hospitalization for both rivaroxaban groups compared with standard therapy one ( Gibson et al, 2017 ). It is important to note that, similar to the WOEST, the PIONEER trial was not powered for an efficacy outcome ( Bhatt, 2016 ); furthermore, patients at very high stroke risk were excluded, as well as those with unknown cause anemia, creatinine clearance <30 mL/min, recent history of significant gastrointestinal bleeding ( Alexopoulos et al, 2017 ). Although a fair percentage of ≥65 years aged patients in the trial, (more than 70% of entire population, with ≥75 years aged accounting to more than 33%) ( Gibson et al, 2016 ), all the above mentioned exclusion criteria present in the trials are frequently found in the real world older patients.…”

One-year outcomes in anticoagulated atrial fibrillation patients undergoing percutaneous coronary intervention: insights from the Greek Antiplatelet Atrial Fibrillation (GRAPE-AF) registry

“…Triple antithrombotic therapy (TAT), consisting of an oral anticoagulant (OAC) plus dual antiplatelet therapy, was until recently the default strategy to reduce atherothrombotic complications; although with the caveat of increased bleeding risk. 1,2 Lately, the role of TAT has been downgraded compared with dual antithrombotic therapy (DAT) with OAC plus a single antiplatelet agent, mainly driven by the reduction of bleeding event rates, without an apparent trade-off in prevention of ischemic events. 3 The latter is supported by recent randomized controlled trials (RCTs) and meta-analyses comparing antithrombotic regimens with novel OACs (NOACs) or vitamin K antagonists (VKAs), which highlight the superiority of DAT versus TAT regarding bleeding complications and recommend the use of NOAC plus a P2Y 12 inhibitor without aspirin, as a favorable option for most AF patients undergoing PCI.…”