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| FELLOWS FORUM |
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| Year : 2015 | Volume
: 1
| Issue : 2 | Page : 198-199 |
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Double trouble: Drug-eluting stenting in a patient of atrial fibrillation
Danny Kumar
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| Date of Web Publication | 30-Sep-2015 |
Correspondence Address:
Dr. Danny Kumar
All India Institute of Medical Scienes, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2395-5414.166331
Stroke prevention is important in patients with atrial fibrillation. Dual antiplatelets are important after a drug coated stent implant in patients with coronary artery disease, while patients with atrial fibrillation need anticoagulation. When to give triple therapy with combination dual antiplatelets and anticoagulation and how to balance the risk and benefits is discussed in this article. Keywords: Anti platelet, atrial fibrillation, drug coated stent, oral anticoagulation
How to cite this article:
Kumar D. Double trouble: Drug-eluting stenting in a patient of atrial fibrillation. J Pract Cardiovasc Sci 2015;1:198-9 |
Stroke prevention is a major part of the management of atrial fibrillation (AF). In nonvalvular AF patients with a CHA2DS2-VASC score ≥2, oral anticoagulant (OAC) Vitamin K antagonists (VKA), or new OACs (NOACs) reduce stroke risk substantially higher than antiplatelet drugs (whether single or dual).[1],[2]
Age is one of the most important risk factors for AF and also for coronary artery disease (CAD). The overall incidence of CAD in AF is >30% (40% in >70 years); among them >20% are vascularized either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting.[3] CAD patient after drug-eluting stenting (DES) placement whether electively or in acute coronary syndrome (ACS) setting should be on dual anti-platelet (DAPT) for the prevention of stent thrombosis. The trouble doubles if an AF patient gets a DES placement and need triple therapy. Triple therapy (OAC and double antiplatelet) increases the risk of major bleeding.
So, what should be appropriate in this setting? The answer is not straightforward.
The HAS-BLED score gives an answer in a better way. Patients with HAS-BLED score ≥3 have a high risk of a major bleed and so triple therapy should not be given more than 4 weeks. With low bleeding risk, (HAS-BLED 0–2), triple therapy should be used for 3–6 month, if not, at least for 4 weeks, and thereafter VKA and clopidogrel should be continued for 12 months.[4] The use of procedural or ticagrelor as part of triple therapy should be avoided, given the lack of established benefit and the greater risk of major bleeding. Because acetylsalicylic acid (ASA) increases the rate of bleeding in a dose-dependent manner,[5],[6] consideration should be given to reducing ASA to low-dose (81 mg) at discharge. These recommendations are from the European Society of Cardiology [Figure 1].[5]
Gastric acid-suppressing agents to reduce gastrointestinal bleeding, preferably a proton pump inhibitor (PPI), should be given. If a PPI is used, an agent that interferes less with CYP2C19 activity and clopidogrel-mediated effects (e.g., pantoprazole) should be preferred. Concomitant nonsteroidal anti-inflammatory agent use should be avoided. Warfarin should be dose-adjusted and closely monitored to maintain the international normalized ratio between 2 and 2.5.
The What is the Optimal Antiplatelet and Anticoagulant Therapy in Patients with Oral Anticoagulation and Coronary Stenting (WOEST) trial. trial showed that in 573 patients taking long-term OAC who received a coronary stent, combination therapy with OAC, and clopidogrel was associated with less total bleeding complications (without significant differences in major bleeds), with no detectable increase in the rate of thrombotic events, especially stent thrombosis. The trial was powered to detect differences in the primary endpoint of any (e.g., thrombolysis in myocardial infarction major plus minor) bleeding event within 1-year of follow-up. Furthermore, there was a significant reduction in mortality at 12 months with dual therapy.[7]
There are some important issues that may limit the conclusions of the WOEST trial: Only 69% of patients received OAC due to AF. Most of the patients underwent elective PCI (70–75%), and the femoral approach was used in 74%, increasing access site bleeding. Furthermore, the differences between dual and triple therapy for the primary endpoint of “all bleeding” were driven by minor bleeding events, PPIs were not used routinely and triple therapy was continued for 12 months (and thus, the increased risk of bleeding is unsurprising).
| New Oral Anticoagulant | |  |
Today, there is no strong evidence that NOACs behave differently to VKA in the setting of ACS or stenting. In ACS patients, who develop a new-onset AF while on DAPT, OAC, either with VKA or NOAC, should be started. The duration of triple therapy depends on the individual risk for ischemic/bleeding events.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management of atrial fibrillation: Review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Ann Intern Med 2003;139:1018-33.  |
| 2. | 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. |
| 3. | Kralev S, Schneider K, Lang S, Süselbeck T, Borggrefe M. Incidence and severity of coronary artery disease in patients with atrial fibrillation undergoing first-time coronary angiography. PLoS One 2011;6:e24964. |
| 4. | Lip GY, Windecker S, Huber K, Kirchhof P, Marin F, Ten Berg JM, et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: A joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J 2014;35:3155-79. |
| 5. | Holmes DR Jr, Kereiakes DJ, Kleiman NS, Moliterno DJ, Patti G, Grines CL. Combining antiplatelet and anticoagulant therapies. J Am Coll Cardiol 2009;54:95-109. |
| 6. | CURRENT-OASIS Investigators, Mehta SR, Bassand JP, Chrolavicius S, Diaz R, Eikelboom JW, et al. Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med 2010;363:930-42. |
| 7. | Dewilde WJ, Oirbans T, Verheugt FW, Kelder JC, De Smet BJ, Herrman JP, 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. Lancet 2013;381:1107-15. |
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