Triple Therapy for Atrial Fibrillation and Percutaneous Coronary Intervention: A Contemporary Review
Study Question:
What is the optimal antiplatelet regimen in patients undergoing percutaneous coronary intervention (PCI) who are also taking a vitamin K antagonist (VKA) for atrial fibrillation (AF)?
Methods:
This review discusses the evidence base for the management of patients on a VKA, and who are undergoing PCI. The authors discuss the existing European and North American guidelines, and also present new information from recent studies.
Results:
The European guidelines (2010) recommend triple therapy (aspirin + clopidogrel + VKA) in patients with AF undergoing PCI. The 2014 North American Guidelines recommend the VKA + clopidogrel (dual therapy). Data from a randomized trial (WOEST, n = 573 patients) showed that dual therapy was associated with a lower incidence of serious bleeding, transfusion requirement, and ischemic events. Data from a Danish registry of 12,165 patients with AF who experienced a myocardial infarction or underwent PCI suggested that, as compared to triple therapy, there was no increased risk of recurrent coronary events or mortality in patients taking dual therapy, and the bleeding risk was nonsignificantly lower. Preliminary studies in patients taking one of the novel oral anticoagulants (NOAC) presenting with an acute coronary syndrome have revealed more bleeding, but without a reduction in ischemic events.
Conclusions:
The authors favor dual therapy with a VKA and clopidogrel in patients with AF undergoing PCI since it appears to be associated with a lower risk of bleeding, but without an increase in thrombotic events.
Perspective:
Major bleeding and transfusion requirement are associated with increased risk of death in patients undergoing PCI. The authors make a reasonable argument in favor of dual therapy in an effort to minimize the bleeding risk. In patients receiving a VKA or a NOAC who also require clopidogrel and/or aspirin, the recently updated European consensus document advocates for a lower international normalized ratio (INR) target (2.0-2.5) and the lower tested dose of the NOAC. Data from large randomized trials are required to validate these recommendations, which are primarily based on registry data.
