Population: Adults with AF requiring treatment for CAD.
Organization
ACC/AHA/ESC 2014
Recommendations
–In patients with AF undergoing PCI, continue DOAC, start P2Y12 inhibitor but start aspirin only for 1 mo.
–Choose bare-metal stents if triple anticoagulation therapy is required. Reserve drug-eluting stents for high-risk clinical or anatomic situations (diabetic patients or if the coronary lesions are unusually long, totally occlusive, or in small blood vessels) if triple anticoagulation therapy is required.
–Dual antiplatelet therapy with clopidogrel (75 mg/d) and ASA (81 mg/d) is the most effective therapy to prevent coronary stent thrombosis.
–If dual antiplatelet or triple anticoagulation therapy, give prophylactic GI therapy with an H2-blocker (except cimetidine) or PPI agent. If considering omeprazole (Prilosec), review the risk-to-benefit ratio because of its possible interference with clopidogrel function.
Practice Pearl
• Triple anticoagulation therapy is the most effective therapy to prevent both coronary stent thrombosis and the occurrence of embolic strokes in high-risk patients. However, the addition of warfarin to DAPT increases the bleeding risk by 3.7-fold. The HAS-BLED (see Table 19–6) bleeding risk score is the best measure of bleeding risk. A high risk of bleeding is defined by a score >3.
Sources
–Circulation. 2014;130(23).
–Eur Heart J. 2010;31:2369-2429.
–BMJ. 2008;337:a840.
–Chest. 2011;139:981-987.
–J Am Coll Cardiol. 2008;51:172-208; 2009;54:95-109; 2010;56:2051-2066; 2011;57:1920-1959.
–J Am Coll Cardiol. 2022;79(2):e21.