Antiplatelet Therapy in Acute Coronary Syndrome and Atrial Fibrillation: Aspirin

Abstract Antithrombotic therapy plays an essential role in the management of some of the most common and morbid medical conditions. Triple oral antithrombotic therapy (TOAT) is defined as the administration of both therapeutic oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT) to patients with indications for both treatments. The current societal guidelines regarding TOAT are derived from observational studies and some trials of the use of warfarin in addition to antiplatelet therapy in patients with atrial fibrillation and a recent acute coronary syndrome or percutaneous coronary intervention. The general apprehension to administer TOAT is due to the heightened concern for bleeding, rendering warfarin's pharmacokinetic properties concerning. Newer anticoagulant agents may serve as appealing alternatives, and further investigations are warranted. The results of the recent trials that have studied the use of these agents in atrial fibrillation and acute coronary syndrome offer some useful applications to TOAT. Ultimately, selecting the most favorable antithrombotic strategy is going to involve weighing the risks and benefits for each patient.

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Clopidogrel as a part of double disaggregant therapy in ACS: a reasonable choice in complex clinical situations

Medical Council ◽

10.21518/2079-701x-2019-5-20-29 ◽

2019 ◽

pp. 20-29 ◽

Cited By ~ 1

Author(s):

V. V. Kashtalap ◽

O. L. Barbarash

Keyword(s):

Atrial Fibrillation ◽

Acute Coronary Syndrome ◽

Antiplatelet Therapy ◽

Clinical Case ◽

Correct Selection ◽

Coronary Syndrome ◽

Hemorrhagic Events ◽

Register Studies ◽

Reasonable Choice ◽

Selection Of

Based on the recommendations of the European Heart Society and the results of clinical and register studies, the article highlights the complex issues that arise when prescribing antiplatelet therapy in patients with acute coronary syndrome, including with concomitant atrial fibrillation (AF); the promising strategies for managing the risk of ischemic and hemorrhagic events are described. Also a clinical case of a patient with acute coronary syndrome and AF is presented, illustrating the objective complexity of correct selection of antiplatelet therapy in such patients.

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Results of Register in Patients with Acute Coronary Syndrome and Atrial Fibrillation Receiving Rivaroxaban

Kardiologiia ◽

10.18087/cardio.2021.6.n1630 ◽

2021 ◽

Vol 61 (6) ◽

pp. 52-58

Author(s):

O. А. Baturina ◽

D. A. Andreev ◽

D.i A. Sychev ◽

D. F. Mesitskaya ◽

S. V. Andranovich ◽

...

Keyword(s):

Atrial Fibrillation ◽

Acute Coronary Syndrome ◽

Antiplatelet Therapy ◽

Composite Endpoint ◽

Medical Attention ◽

Antiplatelet Treatment ◽

Ischemic Cerebrovascular Disease ◽

Coronary Syndrome ◽

Hemorrhagic Complications ◽

Risk Patients

Aim To evaluate outcomes in patients with acute coronary syndrome and atrial fibrillation who receive rivaroxaban and the patients’ compliance with the antithrombotic therapy.Material and methods The study was performed from October 2017 through December 2019 and included 129 patients. Events between the discharge from the hospital and 12 months of follow-up were recorded. The primary endpoint was development of major, minor or requiring medical attention bleeding according to the TIMI scale. The secondary endpoint was a combination of recurrent myocardial infarction, nonfatal acute ischemic cerebrovascular disease, nonfatal systemic embolism, stent thrombosis, and cardiovascular mortality.Results 32 (24.8%) patients early terminated the antiplatelet treatment and 22 (17.1%) patients terminated the rivaroxaban treatment. 26 (20.2 %) patients had hemorrhagic complications. The highest incidence of hemorrhage was observed within the first 2 months after the discharge. None of the bleedings was fatal. Composite endpoint events were observed in 24 (18.6 %) patients, including 14 (10.9 %) who died from cardiovascular causes.Conclusion The compliance with the antiplatelet therapy was insufficient. The incidence of hemorrhagic complications was relatively high; minor and requiring medical attention hemorrhages mostly contributed to the structure of these complications. The observed incidence of recurrent ischemic events associated with a high mortality presents a more serious problem compared to hemorrhagic complications of the combination antiplatelet therapy and warrants a more aggressive tactics of the antiplatelet treatment in high-risk patients.

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Anticoagulant and antiplatelet therapy choices for patients with atrial fibrillation one year after coronary stenting or acute coronary syndrome

Expert Opinion on Drug Safety ◽

10.1080/14740338.2018.1424827 ◽

2018 ◽

Vol 17 (3) ◽

pp. 251-258 ◽

Cited By ~ 1

Author(s):

Christoph B. Olivier ◽

Mintu P. Turakhia ◽

Kenneth W. Mahaffey

Keyword(s):

Atrial Fibrillation ◽

Acute Coronary Syndrome ◽

Antiplatelet Therapy ◽

Coronary Stenting ◽

Coronary Syndrome ◽

One Year

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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?

Journal of Clinical Medicine ◽

10.3390/jcm9082673 ◽

2020 ◽

Vol 9 (8) ◽

pp. 2673

Author(s):

Ugo Limbruno ◽

Francesco De Sensi ◽

Alberto Cresti ◽

Andrea Picchi ◽

Fabio Lena ◽

...

Keyword(s):

Atrial Fibrillation ◽

Acute Coronary Syndrome ◽

Antiplatelet Therapy ◽

Antithrombotic Therapy ◽

Dual Antiplatelet Therapy ◽

Controlled Trial ◽

Complex Situation ◽

P2y12 Inhibitors ◽

Coronary Syndrome ◽

Number Of Patients

The combination of atrial fibrillation (AF) and acute coronary syndrome (ACS) is a complex situation in which a three-dimensional risk—cardioembolic, coronary, and hemorrhagic—has to be carefully managed. Triple antithrombotic therapy (TAT) is burdened with a high risk of serious bleeding, while dual antithrombotic therapy with an anticoagulant (DAT) likely provides only suboptimal coronary protection early after stent implantation. Moreover, TAT precludes the advantages provided by the use of the latest and more potent P2Y12 inhibitors in ACS patients. Here, we aimed to simulate and compare the expected coronary, cardioembolic, and hemorrhagic outcomes offered by DAT, TAT, or modern dual antiplatelet therapy (DAPT) with aspirin plus one of the latest P2Y12 inhibitors in AF patients early after an ACS. The comparison of numbers needed to treat to prevent major adverse events with the various antithrombotic regimens suggests that AF–ACS patients at high ischemic and hemorrhagic risk and at moderately low embolic risk (CHA2DS2VASc score 2–4) might safely withhold anticoagulation after revascularization for one month taking advantage of a modern DAPT, with a favorable risk-to-benefit ratio. In conclusion, this strategy, not sufficiently addressed in recent European and North American guidelines or consensus documents, adds to the spectrum of treatment options in these difficult patients; it might be the best choice in a substantial number of patients; and should be prospectively tested in a randomized controlled trial.

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