Optimal Antithrombotic Treatment of Patients with Atrial Fibrillation Early after an Acute Coronary Syndrome—Triple Therapy, Dual Antithrombotic Therapy with an Anticoagulant… Or, Rather, Temporary Dual Antiplatelet Therapy?

Figure 1. Coronary angiography in the patient case described in the case vignette. (A) The right coronary artery shows a tight stenosis in the mid segment (culprit lesion). (B) The left anterior descending coronary artery shows a long 75% maximum diameter stenosis in the proximal and mid segments.

Figure 2. Percutaneous coronary intervention in the patient case described in the case vignette. (A) The right coronary artery lesion was treated with the implant of a Xience Prime (2.75 × 28 mm) stent. (B) The proximal and mid left anterior descending coronary artery lesions were treated with the implantation of three Xience Prime (3.0 × 38 mm, 3.0 × 15 mm, 2.75 × 15 mm) stents.

Figure 3. Coronary angiography at readmission in the patient case described in the case vignette. Subacute stent thrombosis, with a total vessel occlusion in the left anterior descending coronary artery three days after the percutaneous coronary intervention (PCI) illustrated in Figure 2.

Figure 4. Calculated comparative numbers needed to treat and to prevent stroke or coronary events at 30 days for various antithrombotic drug combinations in patients with atrial fibrillation and a recent coronary stenting for an acute coronary syndrome. NNTBs for coronary events deriving from the use of DAPT with ticagrelor instead of DAT with clopidogrel appear to be lower than the NNTBs for stroke deriving from the use of DAT instead of DAPT for CHA2DS2VASc scores < 4. NNTBs for coronary events deriving from the use of DAPT with prasugrel instead of DAT with clopidogrel appear to be lower than the NNTBs for stroke deriving from the use of DAT instead of DAPT for CHA2DS2VASc scores <5. In case of high-complexity PCI, the event ratio favors DAPT with both ticagrelor and prasugrel at any CHA2DS2VASc score. See the Online Appendix of [15] for calculations of different 30-day NNTBs comparing different antithrombotic strategies. Complex PCI is defined as at least three of the following features: long, bifurcated, eccentric, thrombotic, tortuous, angulated or calcified lesions, left main PCI, and multiple vessel PCI [16]. Abbreviations: ACS: acute coronary syndrome; DAPT: dual antiplatelet…

Figure 5. Bleeding hazard ratios for different antithrombotic treatments. (A) Direct comparisons from randomized trials or observational studies. References are reported for each hazard ratio. (B) Indirect network comparisons of different antithrombotic treatments.