The objective of this manuscript is to review the contemporary literature on the concomitant use of antithrombotic and antiplatelet therapy in patients with atrial fibrillation (AF) and coronary artery disease (CAD) after undergoing percutaneous coronary intervention (PCI). Special consideration was given to the type and duration of therapy, treatment strategies for the elderly (≥65 years of age), and strategies to reduce bleeding.
Relevant studies were searched through MEDLINE/PubMed, Web of Science, Cochrane Library, ClinicalTrials.gov and Google Scholar. Of the 236 publications retrieved, 76 were considered relevant including: 35 randomized controlled trials (RCTs), 17 meta-analyses, 16 observational studies and 8 published major guidelines.
Most trials, meta-analyses and guidelines support either 1 month of triple therapy (TT) with an oral anticoagulant (OAC), dual antiplatelet agents (DAPT) with aspirin (ASA)/clopidogrel and afterwards dual therapy (DT) with OAC and single antiplatelet agent for an additional 11 months or alternatively DT alone for 12 months post-PCI. Individual consideration is given to the risk and impact of both stent thrombosis (ST), thromboembolism, and bleeding. Several trials and meta-analyses have also suggested that shorter DAPT duration (≤6 months) may be safer than longer therapy (≥6 months) when weighing the risk of bleeding with ischemic outcomes, especially with newer generation drug-eluting stents (DES). The selective use of proton pump inhibitors (PPIs) in patients prone to gastrointestinal bleeding (GIB) who are subjected to prolonged exposure with TT or DT may be beneficial. In the elderly the risk of bleeding from TT, compared with DT, outweighs the benefit of reducing ischemic events.
In conclusion, tailoring therapy to the individual patient is recommended considering the ischemic and bleeding risk as well as the risk for thromboembolism. For most AF patients 1 month of TT, and subsequently DT for additional 11 months is recommended.