Journal of the Practice of Cardiovascular Sciences

FELLOWS FORUM
Year
: 2015  |  Volume : 1  |  Issue : 2  |  Page : 198--199

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

Correspondence Address:
Dr. Danny Kumar
All India Institute of Medical Scienes, New Delhi
India

Abstract

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.



How to cite this article:
Kumar D. Double trouble: Drug-eluting stenting in a patient of atrial fibrillation.J Pract Cardiovasc Sci 2015;1:198-199


How to cite this URL:
Kumar D. Double trouble: Drug-eluting stenting in a patient of atrial fibrillation. J Pract Cardiovasc Sci [serial online] 2015 [cited 2022 May 22 ];1:198-199
Available from: https://www.j-pcs.org/text.asp?2015/1/2/198/166331


Full Text

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]{Figure 1}

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

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