Anticoagulation strategies in patients with atrial fibrillation after PCI or with ACS: The end of triple therapy?

TY - JOUR

T1 - Anticoagulation strategies in patients with atrial fibrillation after PCI or with ACS: The end of triple therapy?

AU - Fluschnik, N

AU - Becher, P M

AU - Schnabel, R

AU - Blankenberg, S

AU - Westermann, D

PY - 2018/2

Y1 - 2018/2

N2 - Clinicians struggle daily with the optimal regimen for patients with an indication for antiplatelet therapy after stenting and in patients needing oral anticoagulation treatment for atrial fibrillation (AF). This is not only difficult in patients with acute coronary syndrome (ACS) but also in the large number of patients with AF undergoing elective percutaneous coronary intervention (PCI). The challenge is to strike a balance between the increasing risk of bleeding events and ischemic or thrombotic events. Until recently, guidelines were based on expert consensus and a few small, many of them retrospective, trials. A so-called triple therapy with a vitamin K antagonist (VKA) and dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was recommended for patients with AF undergoing PCI in stable coronary artery disease or for those with ACS. However, severe bleeding complications remain a major issue during triple therapy, particularly in the growing aging population. In the past year, randomized controlled trials (RCT) with direct-acting oral anticoagulants (DOACs) have modified the standard use of care, now favoring dual therapy with DOACs. This review elucidates the current influential RCTs on the new antiplatelet and anticoagulation strategies for patients with AF undergoing PCI or with ACS, and discusses whether triple therapy is still required.

AB - Clinicians struggle daily with the optimal regimen for patients with an indication for antiplatelet therapy after stenting and in patients needing oral anticoagulation treatment for atrial fibrillation (AF). This is not only difficult in patients with acute coronary syndrome (ACS) but also in the large number of patients with AF undergoing elective percutaneous coronary intervention (PCI). The challenge is to strike a balance between the increasing risk of bleeding events and ischemic or thrombotic events. Until recently, guidelines were based on expert consensus and a few small, many of them retrospective, trials. A so-called triple therapy with a vitamin K antagonist (VKA) and dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was recommended for patients with AF undergoing PCI in stable coronary artery disease or for those with ACS. However, severe bleeding complications remain a major issue during triple therapy, particularly in the growing aging population. In the past year, randomized controlled trials (RCT) with direct-acting oral anticoagulants (DOACs) have modified the standard use of care, now favoring dual therapy with DOACs. This review elucidates the current influential RCTs on the new antiplatelet and anticoagulation strategies for patients with AF undergoing PCI or with ACS, and discusses whether triple therapy is still required.

KW - Acute Coronary Syndrome/drug therapy

KW - Administration, Oral

KW - Anticoagulants/adverse effects

KW - Aspirin/adverse effects

KW - Atrial Fibrillation/drug therapy

KW - Clopidogrel/adverse effects

KW - Drug Therapy, Combination

KW - Guideline Adherence

KW - Hemorrhage/chemically induced

KW - Humans

KW - Percutaneous Coronary Intervention

KW - Platelet Aggregation Inhibitors/adverse effects

KW - Postoperative Complications/drug therapy

KW - Randomized Controlled Trials as Topic

KW - Risk Factors

KW - Stents

KW - Stroke/prevention & control

KW - Thrombosis/prevention & control

KW - Vitamin K/antagonists & inhibitors

U2 - 10.1007/s00059-017-4649-z

DO - 10.1007/s00059-017-4649-z

M3 - SCORING: Journal article

C2 - 29188358

VL - 43

SP - 20

EP - 25

JO - HERZ

JF - HERZ

SN - 0340-9937

IS - 1

ER -