Key result
Triple therapy comprising an oral anticoagulant, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS, with DOACs being safer than vitamin-K antagonists.
Why the study?
Patients with AF undergoing stenting for ACS or CAD present a clinical dilemma balancing bleeding risk and atherothromboembolic events when combining OACs with antiplatelet therapy.
Does the combination of oral anticoagulants and single antiplatelets compared to triple therapy optimize the balance between bleeding risk and atherothromboembolic events in Asian patients with nonvalvular AF and ACS/CAD?
Does the combination of oral anticoagulants and single antiplatelets compared to triple therapy optimize the balance between bleeding risk and atherothromboembolic events in Asian patients with nonvalvular AF and ACS/CAD?
This review highlights that for Asian patients with nonvalvular AF and ACS, triple therapy with a DOAC is preferred for 1 to 6 months to balance ischemic and bleeding risks.
May guide antithrombotic duration in AF-ACS stenting; leaves open optimal regimens by bleeding risk in Asians.
Atrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)–vascular disease, age 65 to 74 years, sex category (female; CHA2DS2-VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, “triple therapy” comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for “triple therapy” would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.
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Santoso et al. (2020) conducted a review in Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome. Direct-acting oral anticoagulants (DOACs) and antiplatelet therapy vs. Vitamin-K antagonists / Triple therapy was evaluated. Triple therapy comprising an oral anticoagulant, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS, with DOACs being safer than vitamin-K antagonists.
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