Direct Oral Anticoagulants and Coronary Artery Disease

Coronary artery disease is a leading cause of morbidity and mortality worldwide. Acute coronary syndrome as a first presentation is common and patients with established disease have a high rate of recurrent ischemic events, despite antiplatelet therapy. Over the past several years, direct oral anticoagulants have become available and have been studied in patients with coronary artery disease. These medications directly inhibit either thrombin or factor Xa which contribute to atherothrombosis. This review will summarize the clinical data regarding the use of direct oral anticoagulants in different patient populations with coronary disease and the balance between protection against ischemia and bleeding. Additionally, the review will summarize the available data on the use of direct oral anticoagulants periprocedurally in patients undergoing percutaneous coronary intervention. The future direction of coronary artery disease and the role of direct oral anticoagulants will rely on further studies determining the optimal combination of antiplatelet and oral anticoagulant regimens that derive ischemic benefit without increased rates of bleeding. Additional upstream blockade of the coagulation cascade with factor XIIa and factor XIa inhibitors may also improve treatment in the future.