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CC BY-NC-ND 4.0 · Avicenna J Med 2019; 09(04): 123-128
DOI: 10.4103/ajm.AJM_73_19
REVIEW ARTICLE

Antithrombotic therapy in patients with atrial fibrillation and coronary artery disease

Abdelmoniem Moustafa
Department of Internal Medicine and Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
,
Mohammad Ruzieh
Department of Internal Medicine and Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
,
Ehab Eltahawy
Department of Internal Medicine and Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
,
Saima Karim
Department of Internal Medicine and Cardiology, University of Toledo Medical Center, Toledo, Ohio, USA
› Author Affiliations Financial support and sponsorship Nil.
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Abstract

Atrial fibrillation and coronary artery disease are commonly coexisting conditions that necessitate the use of an oral anticoagulant as well as dual antiplatelet therapy. Commonly referred to as triple oral antithrombotic therapy (TT), this helps prevent ischemic stroke and myocardial infarction but comes at the expense of an increased risk of bleeding. There is a growing body of evidence that the omission of aspirin from TT has the same preventive efficacy in terms of major adverse cardiacvascular and cerebrovascular events (MACCE) with significantly lower bleeding events. The combination of antiplatelet agents and direct oral anticoagulants (DOAC) is a matter of ongoing research. However, initial studies showed favorable safety profile of DOAC over vitamin K antagonist in combination with antiplatelet agents.

Keywords

Atrial fibrillation - cad - dual antiplatelet therapy - triple antithrombotic therapy


Publication History

Article published online:
09 August 2021

© 2019. Syrian American Medical Society. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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  • References

  • 1 Nieuwlaat R, Capucci A, Camm AJ, Olsson SB, Andresen D, Davies DW. et al. Atrial fibrillation management: a prospective survey in ESC member countries [Internet]. Eur Heart J 2005; 26: 2422-34
    CrossrefPubMedGoogle Scholar
  • 2 Nabauer M, Gerth A, Limbourg T, Schneider S, Oeff M, Kirchhof P. et al. The registry of the German competence network on atrial fibrillation: patient characteristics and initial management. Europace 2009; 11: 423-34
    CrossrefPubMedGoogle Scholar
  • 3 Elewa H, Ahmed D, Barnes GD. et al. Triple oral antithrombotic therapy in atrial fibrillation and coronary artery stenting: searching for the best combination. Semin Thromb Hemost 2016; 42: 662-70
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Thomsen PEB, Jons C, Pekka RaatikainenMJ, Joergensen RM, Hartikainen J, Virtanen V. et al Long-term recording of cardiac arrhythmias with an implantable cardiac monitor in patients with reduced ejection fraction after acute myocardial infarction [Internet]. Circulation 2010; 122: 1258-64
    CrossrefPubMedGoogle Scholar
  • 5 Rossini R, Musumeci G, Lettieri C, Molfese M, Mihalcsik L, Mantovani P. et al. Long-term outcomes in patients undergoing coronary stenting on dual oral antiplatelet treatment requiring oral anticoagulant therapy. Am J Cardiol 2008; 102: 1618-23
    CrossrefPubMedGoogle Scholar
  • 6 Rubboli A, Colletta M, Valencia J, Capecchi A, Franco N, Zanolla L. et al. WARfarin and Coronary STENTing (WAR-STENT) Study Group. Periprocedural management and in-hospital outcome of patients with indication for oral anticoagulation undergoing coronary artery stenting. J Interv Cardiol 2009; 22: 390-7
    CrossrefPubMedGoogle Scholar
  • 7 Dewilde WJM, Oirbans T, Verheugt FWA, Kelder JC, De Smet BJ, Herrman J-P. et al Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial [Internet]. Lancet 2013; 381: 1107-15
    CrossrefPubMedGoogle Scholar
  • 8 Orford JL, Fasseas P, Melby S, Burger K, Steinhubl SR, Holmes DR. et al. Safety and efficacy of aspirin, clopidogrel, and warfarin after coronary stent placement in patients with an indication for anticoagulation. Am Heart 2004; 147: 463-7
    CrossrefPubMedGoogle Scholar
  • 9 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA. et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease [Internet]. J Am Coll Cardiol 2014; 63: e57-e185
    CrossrefPubMedGoogle Scholar
  • 10 January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019; 25873. Available from: http://www.onlinejacc.org/content/accj/early/2019/01/21/j.jacc.2019.01.011.full.pdf?_ga=2.123833999.444342634.1549998980-1712963828.1549998980.
  • 11 Massachusetts Medical Society. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345:494-502.
  • 12 for Percutaneous Cardiovascular Interventions EA, Others. The task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2010;31:2501-55.
  • 13 Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR. et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary [Internet]. Circulation 2014; 2354-94
    CrossrefPubMedGoogle Scholar
  • 14 Waldo AL. et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the atrial fibrillation clopidogrel trial with irbesartan for prevention of vascular events (ACTIVE W): a randomised controlled trial [Internet]. Yearb Cardiol 2007; 423: 4
    Google Scholar
  • 15 Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007; 146: 857-67
    CrossrefPubMedGoogle Scholar
  • 16 Kamath S, Blann AD, Chin BS, Lip GY. A prospective randomized trial of aspirin-clopidogrel combination therapy and dose-adjusted warfarin on indices of thrombogenesis and platelet activation in atrial fibrillation. J Am Coll Cardiol 2002; 40: 484-90
    CrossrefPubMedGoogle Scholar
  • 17 January CT, Samuel Wann L, Calkins H, Chen LY, Cigarroa JE, Cleveland JC. et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation [Internet]. Circulation 2019; 140: e125-e151
    CrossrefPubMedGoogle Scholar
  • 18 Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B. et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18: 1609-78
    CrossrefPubMedGoogle Scholar
  • 19 Khurram Z, Chou E, Minutello R, Bergman G, Parikh M, Naidu S. et al. Combination therapy with aspirin, clopidogrel and warfarin following coronary stenting is associated with a significant risk of bleeding. J Invasive Cardiol 2006; 18: 162-4
    PubMedGoogle Scholar
  • 20 Rogacka R, Chieffo A, Michev I, Airoldi F, Latib A, Cosgrave J, Sarin YK. et al. Dual antiplatelet therapy after percutaneous coronary intervention with stent implantation in patients taking chronic oral anticoagulation. JACC Cardiovasc Interv 2008; 1: 56-61
    CrossrefPubMedGoogle Scholar
  • 21 Asencio LA, Huang JJ, Alpert JS. Combining antiplatelet and antithrombotic therapy (triple therapy): What are the risks and benefits?. Am J Med 2014; 127: 579-85
    CrossrefPubMedGoogle Scholar
  • 22 Sinha S, Faxon DP, Eikelboom JW, Berger PB, Holmes DRJr, Bhatt DL, Moliterno DJ. et al Antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting: a North American perspective: executive summary. Circ Cardiovasc Interv 2011; 4: 522-34
    CrossrefPubMedGoogle Scholar
  • 23 Hart RG, Diener HC, Yang S, Connolly SJ, Wallentin L, Reilly PA. et al. Intracranial hemorrhage in atrial fibrillation patients during anticoagulation with warfarin or dabigatran: the RE-LY trial. Stroke 2012; 43: 1511-7
    CrossrefPubMedGoogle Scholar
  • 24 Fiedler KA, Maeng M, Mehilli J, Schulz-Schüpke S, Byrne RA, Sibbing D. et al. Duration of triple therapy in patients requiring oral anticoagulation after drug-eluting stent implantation: the ISAR-TRIPLE trial. J Am Coll Cardiol 2015; 65: 1619-29
    CrossrefPubMedGoogle Scholar
  • 25 Konishi H, Miyauchi K, Kasai T, Tsuboi S, Ogita M, Naito R. et al. Adequate time in therapeutic INR range using triple antithrombotic therapy is not associated with long-term cardiovascular events and major bleeding complications after drug-eluting stent implantation [Internet]. J Cardiol 2016; 68: 517-522
    CrossrefPubMedGoogle Scholar
  • 26 Gibson CM, Michael Gibson C, Mehran R, Bode C, Halperin J, Verheugt FW. et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI [Internet]. N Engl J Med 2016; 375: 2423-34
    CrossrefPubMedGoogle Scholar
  • 27 Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W. et al. ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011; 365: 883-91
    CrossrefPubMedGoogle Scholar
  • 28 Cannon CP, Bhatt DL, Oldgren J, Lip GHY, Ellis SG, Kimura T. et al RE-DUAL PCI Steering Committee and Investigators. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med 2017; 377: 1513-24
    CrossrefPubMedGoogle Scholar
  • 29 Lopes RD, Heizer G, Aronson R, Vora AN, Massaro T, Mehran R. et al. AUGUSTUS Investigators.Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med 2019; 380: 1509-24
    CrossrefPubMedGoogle Scholar
  • 30 Agarwal N, Jain A, Mahmoud AN, Bishnoi R, Golwala H, Karimi A. et al. Safety and efficacy of dual versus triple antithrombotic therapy in patients undergoing percutaneous coronary intervention. Am J Med 2017; 130: 1280-9
    CrossrefPubMedGoogle Scholar
  • 31 Golwala HB, Cannon CP, Steg PG, Doros G, Qamar A, Ellis SG. et al. Safety and efficacy of dual vs Triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of randomized clinical trials. Eur Heart J 2018; 39: 1726-35
    CrossrefPubMedGoogle Scholar
  • 32 Oldgren J, Budaj A, Granger CB, Khder Y, Roberts J, Siegbahn A. et al. RE-DEEM Investigators Dabigatran vs placebo in patients with acute coronary syndromes on dual antiplatelet therapy: a randomized, double-blind, phase II trial. Eur Heart J 2011; 32: 2781-9
    CrossrefPubMedGoogle Scholar
  • 33 Alexander JH, Becker RC, Bhatt DL, Cools F, Crea F, Dellborg M. et al. APPRAISE Steering Committee and Investigators. Apixaban, an oral, direct, selective factor Xa inhibitor, in combination with antiplatelet therapy after acute coronary syndrome: results of the Apixaban for Prevention of Acute Ischemic and Safety Events (APPRAISE) trial. Circulation 2009; 119: 2877-85
    CrossrefPubMedGoogle Scholar
  • 34 Braun OÖ, Bico B, Chaudhry U, Wagner H, Koul S, Tydén P, et al Concomitant use of warfarin and ticagrelor as an alternative to triple antithrombotic therapy after an acute coronary syndrome. Thromb Res 2015; 135: 26-30
    CrossrefPubMedGoogle Scholar
  • 35 Lu W, Chen L, Wang Y, Yao Y, Fu C, Zuo P. et al. Rationale and design of MANJUSRI trial: A randomized, open-label, active-controlled multicenter study to evaluate the safety of combined therapy with ticagrelor and warfarin in AF subjects after PCI-eS [Internet]. Contemp Clin Trials 2015; 40: 166-71
    CrossrefPubMedGoogle Scholar