Antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention

Abstract

The management of atrial fibrillation (AF) in patients who have undergone percutaneous coronary intervention (PCI) with stent implantation is challenging. Oral anticoagulation has been shown to significantly reduce the risk of stroke in AF, whereas dual antiplatelet therapy prevents major adverse cardiovascular events, including stent thrombosis after PCI. A typical triple antithrombotic therapy, involving an anticoagulant, i.e. vitamin K antagonist (VKA), together with aspirin and P2Y12 inhibitor, usually clopidogrel, has been shown to minimize ischemic and stroke risks, but is associated with increased risk of major bleeding. The use of dabigatran, rivaroxaban, or apixaban in combination with antiplatelet agents lowers the risk of major bleeding and makes it an option preferred over triple therapy in the majority of PCI patients with AF. The consistency across randomized controlled trials on combination therapy with non-vitamin K antagonist oral anticoagulant (NOAC) and clopidogrel, including patients with acute coronary syndromes, led to changes in everyday practice. However, the use of triple and dual antithrombotic therapy at high bleeding risk should be individualized. The present review summarizes available data on the efficacy and safety of antithrombotic therapy in AF patients undergoing PCI in the era of NOAC.