Contemporary review on the management of oral anticoagulation and anti-platelet therapies in patients undergoing percutaneous coronary intervention with concurrent atrial fibrillation

Abstract

Management of coronary artery disease (CAD) with percutaneous coronary intervention (PCI) in the setting of atrial fibrillation (AF) presents clinicians with the challenge of balancing thrombosis risk with bleeding risk. Major societies including American College of Cardiology (ACC)/American Heart Association (AHA), Heart Rhythm Society (HRS) and European Society of Cardiology (ESC) guideline recommendations include the necessity to use antiplatelet therapy and anticoagulation for the prevention of thromboembolism in patients who undergo intervention with PCI who have concurrent AF. Dual antiplatelet therapy (DAPT) is the standard of care for patients post PCI, and anticoagulation with vitamin K antagonists (VKA) or direct acting oral anticoagulants (DOAC) is the standard of care, with DOACS being recommended by ACC/AHA and ESC as preferred, for patients with AF and elevated ischemic stroke risk. Here, we review the contemporary major society guideline recommendations applicable for the use of triple therapy with dual anti-platelet agents and oral anticoagulant, in patients undergoing PCI who have concurrent AF. We also review and summarize the relevant historical primary literature related to the approval of antiplatelet and anticoagulant therapy in PCI and AF respectively. Using a case description as a basis to illustrate this difficult clinical scenario, we review the contemporary literature, and present proposed management algorithms.