Antithrombotics in atrial fibrillation and coronary disease

Abstract

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and approximately 18–45% of AF patients have concomitant coronary artery disease (CAD). Several studies have demonstrated that oral anticoagulation is the mainstay of therapy for stroke prevention in AF. Similarly, antiplatelet therapy including aspirin and P2Y12 inhibitor is recommended in the management of acute coronary syndrome and stable CAD. Despite the high prevalence of CAD with AF, practice guidelines are scarce on the appropriate antithrombotic regimen due to lack of large-scale randomized clinical trials. The use of direct thrombin and factor Xa inhibitors for stroke prevention in AF has also complicated the possible combinations of antithrombotic therapies. This review aims to discuss the available evidence regarding aspirin as an antithrombotic strategy, the role of novel anticoagulants and the specific clinical situations where aspirin may be beneficial in patients with AF and CAD.

Keywords::

• antithrombotic
• aspirin
• atrial fibrillation
• coronary artery disease
• novel anticoagulants
• warfarin

Financial and competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia affecting 3 million individuals in the USA. Similarly, coronary artery disease (CAD) is estimated to occur in 18–45% of patients with concomitant AF.

• Unlike the CHA₂DS₂-VASc score for AF, there is no validated risk score to predict future thrombosis in CAD.

• Patients with AF in the presence of CAD or peripheral vascular disease are never truly at low risk for systemic thromboembolism including stroke (at least a CHA₂DS₂-VASc of 1).

• Clinical risk assessment of thrombosis and bleeding is recommended in every AF patient with CAD and acute coronary syndrome (ACS).

• The appropriate antithrombotic regimen in stable CAD and ACS in the presence of AF is unclear and based on best practice standards due to a lack of randomized clinical trials.

• Studies involving the role of novel anticoagulants, with the exception of rivaroxaban, in ACS have found them to be unfavorable with increased bleeding risk and they are not recommended.

• Triple antithrombotic therapy may be used in AF patients with high risk of coronary thrombosis in the setting of ACS or stent placement.

• Physicians should be cautious while recommending aspirin along with routine anticoagulation in the absence of a compelling indication due to lack of clear-cut evidence, especially in patients with AF and stable CAD.

• The need for clinical trials to determine the safety and efficacy of such combination antithrombotics remains paramount and is essential for informed decision-making in the management of these challenging patients.

Notes