The combination of anticoagulant and anti-platelet therapy in patients with atrial fibrillation: a comment on the recent ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: reply

We appreciate your comment on the recommendations about anticoagulation in patients with atrial fibrillation (AF) who have undergone PCI. First, it is important to note that these statements appear in the recently published guidelines as a class IIb recommendation (level of evidence C). Since there are no prospective, randomized clinical trials specifically designed to address this issue, they are supported by the weakest level of evidence (consensus opinion of experts).1 Nevertheless, there are some important considerations. The aim of practice guidelines is to guide the treatment of ‘day-to-day’ patients. Those recommendations are drawn from clinical trials, which sometimes included patients who may have different characteristics of patients seen in clinical practice. In relation to the design of these studies about antithrombotic treatment, there are two relevant factors: age and duration of follow-up. Age is a well-known risk factor for bleeding complications, which is the most feared adverse event related to long-term antithrombotic treatment.1 It is known that AF and coronary artery disease are age-related conditions, which implies that most patients with chronic AF undergoing PCI will be at an increased risk of bleeding because of advanced age. However, a large proportion of clinical trials excluded elderly patients. Observational studies can provide useful information about the characteristics and outcome of these patients. In a retrospective study that included 66 patients discharged on triple therapy after PCI, the mean age was 75 years, and almost 40% of patients received anticoagulation for chronic AF2 and 10% of them required medical attention because of bleeding complications, which seems superior to that of clinical trials.2 In a cohort study of patients admitted with a primary or secondary diagnosis of AF, the mean age was 78.8 years and more than two-thirds were ≥75 years of age.3