Adding to the evidence or to the confusion: dual antithrombotic therapy in chronic coronary syndrome and atrial fibrillation

Atrial fibrillation (AF) is the most common arrhythmia in the world with the lifetime risk estimated to be 1/3 in men and women over the age of 50 years.1 Cardiovascular disease, like misfortune, does not come singly in most cases. Coronary artery disease (CAD) with the chronic coronary syndrome (CCS) or acute coronary syndrome (ACS) is a common comorbid condition. Management of patients with AF with a comprehensive treatment of risk factors and concomitant diseases is the key to treat these patients. Yet, the devil is in the details as treatment becomes increasingly complex. Patients with AF and CAD require antiplatelet therapy (APT) in addition to oral anticoagulation (OAC) after myocardial infarction or percutaneous coronary intervention (PCI) for a limited time period. Depending on ischaemic risk, bleeding risk and unplanned PCI, different treatment regimens are available with dual antithrombotic therapy with OAC and APT up to 12 months.2 Looking at each possible combination of drugs and therapy length, the cardiologist is left with 2.8 million possible combinations in the first 12 months only.3 This subanalysis from the recently published randomised controlled ‘Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease Study’ (AFIRE) by Fukaya et al 4 examines whether aspirin or P2Y12 inhibitors (clopidogrel in 94.6%) in addition to rivaroxaban impacts outcomes in patients with CCS. The main trial showed that dual antithrombotic therapy is associated with increased mortality compared with OAC monotherapy in patients with AF and CCS. Patients in the dual antithrombotic arm were compared in regard to additional APT (P2Y12 inhibitors n=297 vs aspirin n=778) and a primary outcome of composite of …