Atrial fibrillation with percutaneous coronary intervention: Navigating the minefield of antithrombotic therapies

Highlights

• This review provides insights into contemporary antithrombotic options for patients with atrial fibrillation undergoing percutaneous coronary intervention.

• Nuances between key international guidelines regarding recommendations for these patients are discussed.

• Evidence supports a dual antithrombotic pathway approach as the recommended therapy for the majority of these patients. If triple antithrombotic therapy is chosen, its duration should be kept as short as possible.

Abstract

This review aims to provide insights into contemporary therapeutic options for the treatment of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) and compares current international guidelines. AF is a common cardiac arrhythmia and a major risk factor for stroke. The risk of stroke can be reduced with the use of oral anticoagulant (OAC) therapy. However, for patients with AF, PCI necessitates the use of combined antithrombotic therapies (OAC and antiplatelet therapies) to reduce thrombotic coronary complications. Optimal combinations and durations of OAC and/or antiplatelet therapy remains an area of clinical debate. Nuances exist within the current guidelines regarding duration and combination of antithrombotic therapy for AF patients requiring PCI. However, consensus was found across the following key points: (i) recent evidence supports a preferred role for a dual antithrombotic approach (OAC plus 1 antiplatelet); (ii) limited use of triple antithrombotic therapy is recommended across all guidelines for patients where the ischemic risk outweighs the risk of bleeding, with the duration to be kept as short as possible; and (iii) lifelong management using monotherapy with an OAC from 12 months post PCI is recommended for stable patients across all guidelines.

Introduction

Atrial fibrillation (AF) is a common cardiac arrhythmia with a higher prevalence in older populations and in patients with existing atherosclerotic disease. Approximately 20–30% of ischemic strokes are related to AF, associated with increased risk of heart failure, cardiovascular morbidity, and mortality [1]. Approximately 3 million patients undergo percutaneous coronary intervention (PCI) each year worldwide [2]. In randomized trials, dual antiplatelet therapy (DAPT; a P2Y₁₂ receptor inhibitor plus aspirin) after PCI reduces the risk of future ischemic or atherothrombotic events, particularly stent-related thrombosis, recurrent myocardial infarction (MI), or cardiovascular death [2]. Clinical trials involving patients treated with newer-generation stents have shown 3–6 months' duration of DAPT to be as effective as 12 months’ therapy after elective PCI [[3], [4], [5], [6], [7], [8]], although in acute coronary syndrome (ACS) patients these results are inconclusive due to a lack of adequately powered trials [9]. In contrast, other studies observed a reduction in the risk of thromboembolic, major adverse cardiovascular and cerebrovascular events with DAPT beyond 1 year with an associated increased risk of bleeding [10,11]. For patients undergoing PCI, approximately 5–10% have concomitant AF or other indications for long-term oral anticoagulant (OAC) therapy [12]. The optimal antithrombotic management of patients undergoing PCI who also have AF has become a clinical conundrum related to the optimal duration and combination of therapies to reduce subsequent ischemic and thromboembolic risk without incurring unacceptably increased bleeding risk [12]. Moreover, the lack of consensus within current guidelines regarding duration and selection of combined therapy adds to this challenge [[13], [14], [15]]. This article will discuss the most recent contemporary therapeutic options for atrial fibrillation patients requiring PCI and compare current European, North American, and Canadian guidelines for the antithrombotic management.