Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Figures

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  Figure 1. Determinants of Thrombotic and Bleeding Risks in Patients with Atrial Fibrillation and Coronary Artery Disease. Figure summarizing major clinical determinants of thromboembolic, coronary ischemic, and bleeding risk in patients with AF and coronary artery disease. The figure is divided into three vertical panels. The first panel, “AF-related cardioembolic risk,” lists factors associated with thromboembolic risk, including prior stroke, TIA, or systemic embolism; advanced age; heart failure; hypertension; diabetes mellitus; vascular disease; and persistent or permanent AF. The second panel, “Coronary ischemic risk,” lists factors associated with recurrent coronary or stent-related ischemic events, including acute coronary syndrome, especially STEMI; the early post-PCI phase; prior stent thrombosis; complex PCI; multivessel CAD; left main or proximal LAD PCI; long stent length or multiple stents; bifurcation PCI; diabetes mellitus; CKD; and PAD. The third panel, “Bleeding risk,” lists factors associated with hemorrhagic complications, including prior major bleeding; prior intracranial hemorrhage; anemia; thrombocytopenia; severe or worsening CKD; liver disease; frailty, falls, or…

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  Figure 2. Randomized Trials of Antithrombotic Strategies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Timeline-based evidence map of randomized trials evaluating antithrombotic strategies in patients with AF across early ACS and/or PCI and stable CAD settings. Trials are displayed in separate panels according to clinical setting and grouped into VKA-based strategies, DOAC-based strategies, and OAC monotherapy strategies. Within each panel, trials are shown chronologically by year of publication, with bubble size proportional to the randomized sample size and bubble fill color identifying the antithrombotic strategy group. The figure illustrates the evolution of randomized evidence from VKA-based combination strategies toward DOAC-based strategies in the early ACS and/or PCI setting and OAC monotherapy strategies in stable CAD. Abbreviations: ACS, acute coronary syndrome; AF, atrial fibrillation; CAD, coronary artery disease; DOAC, direct oral anticoagulant; OAC, oral anticoagulation; PCI, percutaneous coronary intervention; VKA, vitamin K antagonist.

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  Figure 3. Therapeutic Algorithm for Antithrombotic Therapy Management in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Therapeutic algorithm for phase-specific antithrombotic management in patients with AF requiring long-term OAC who present with ACS and/or undergo PCI. The algorithm begins with an index clinical scenario and recommends early TAT for up to 1 week with OAC, clopidogrel, and aspirin. A central risk-based adjustment step allows treatment modification according to bleeding and ischemic risk. In patients with high bleeding risk and low ischemic risk, aspirin omission or discontinuation at discharge may be considered, together with correction of modifiable bleeding risk factors. In patients with high ischemic risk and acceptable bleeding risk, extension of TAT up to 1 month may be considered, with early reassessment of bleeding risk. The intermediate phase consists of DAT with OAC plus clopidogrel. Duration is differentiated by clinical setting: up to 12 months after ACS and up to 6 months in patients with CCS undergoing elective PCI. Both pathways transition to long-term OAC monotherapy. General treatment principles include preferring DOACs…