Antithrombotic treatment in atrial fibrillation patients undergoing percutaneous coronary interventions: focus on stent thrombosis

ABSTRACT

Introduction

Coronary artery disease (CAD) commonly coexists with atrial fibrillation (AF), requiring oral anticoagulation (OAC) in a significant subset of patients. These patients also often require revascularization with percutaneous coronary intervention (PCI), which traditionally is supported with dual antiplatelet therapy (DAPT) to prevent complications including stent thrombosis (ST). Recent clinical studies have demonstrated that dual therapy (DAT, i.e. OAC plus single P2Y₁₂ inhibitor) has a more favorable safety profile than triple antithrombotic therapy (TAT). As none of these trials were sufficiently powered for evaluating ischemic outcomes, some concerns remain regarding ischemic complications, in particular ST, a catastrophic complication of PCI

Areas covered

In this narrative review, we summarize and critically evaluate current data on the efficacy and the safety of DAT vs TAT in AF patients undergoing PCI particularly focusing on their implication in ST.

Expert opinion

The choice of antithrombotic strategy in this context is challenging and requires tailored decision making with careful consideration of bleeding, thrombotic and ischemic risk for each patient. As the risk of thrombosis and bleeding varies from patient to patient, care is moving away from a ‘one size fits all’ therapy approach toward more individualized antithrombotic treatment.

KEYWORDS:

• stent thrombosis
• atrial fibrillation
• anticoagulation
• DAPT
• PCI

Article highlights

• A dual antithrombotic therapy strategy consisting of Non-Vitamin K Antagonist (NOAC) plus a P2Y₁₂ inhibitor is the treatment of choice in the majority of AF patients with concomitant CAD or undergoing PCI

• Though DAT has a safer profile in terms of major bleeding compared to TAT, some concerns have been raised regarding ischemic complications, especially ST, since none of the randomized clinical trials (RCTs) were sufficiently powered to evaluate ischemic outcomes

• Stent thrombosis is a catastrophic event and despite being a rare complication, it is associated with a high mortality rate.

• In most recent meta-analyses of RCTs, DAT is associated with a statistically significant higher risk of ST compared to TAT suggesting that patients at high ischemic and low bleeding risk might benefit from an initial course of NOAC-based triple therapy.

• Clopidogrel is the P2Y₁₂ inhibitor of choice in combination with OAC. Data on safety and efficacy of third-generation P2Y₁₂ inhibitors are scarce but DAT with ticagrelor plus NOAC might possibly represent a reasonable choice in selected patients.

Declaration of interest

G Lip has declared that they are a consultant for Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon and Daiichi-Sankyo; speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi-Sankyo; no fees are directly received personally. D Capodanno declares that he has received consulting fees or honoraria from Amgen, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Daiichi Sankyo, and Sanofi. A Rubboli reports other from Astra Zeneca, Boehringer Ingelheim, Bayer, Pfizer/BMS and DaiichiSankyo. G Boriani has declared they have received a small speaker fee from Medtronic, Boston, Boehringer Ingelheim and Bayer.

The authors have no other 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 apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. 

Additional information

Funding

This paper was not funded.