scholarly journals The patient with atrial fibrillation undergoing percutaneous angioplasty: triple therapy or new therapeutic strategies?

ABOUTOPEN ◽  
2018 ◽  
Vol 4 (1) ◽  
pp. 116-121
Author(s):  
Gianluca Campo ◽  
Giulia Bugani
Keyword(s):  
Atrial Fibrillation ◽  
Triple Therapy ◽  
Antithrombotic Therapy ◽  
Scientific Evidence ◽  
Oral Anticoagulants ◽  
Dual Therapy ◽  
Clinical History ◽  
Bleeding Risk ◽  
Therapeutic Strategies ◽  
Thrombotic Risk

The management of antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is a challenge cardiologists face daily. The main difficulty is represented by finding the right balance between the prevention of thrombotic risk and the inevitable increase in bleeding. Most guidelines recommend the use of both oral anticoagulants and dual antiplatelet therapy in combination (triple therapy) in patients with FA undergoing PCI, suggesting however immediate use of dual antithrombotic therapy in patients with prevalent bleeding risk. Many studies show that triple therapy is associated with high frequency of major bleeding, thus stimulating the research for new therapeutic strategies. We report the case of a patient suffering from hypertension, dyslipidemia and epistaxis, hospitalized for the onset of angina associated with moderate efforts. Despite scientific evidence to support the use of dual therapy with dabigatran, the patient's detailed clinical history shows that this type of approach has not yet entered into current clinical practice, although the final therapeutic choice is in line with the results of the RE-DUAL PC study (Cardiology).

Antithrombotic therapy in patients with atrial fibrillation undergoing coronary artery stenting

2019 ◽  
Vol 76 (18) ◽  
pp. 1395-1402
Author(s):  
Jordan L Lacoste ◽  
Cory L Hansen
Keyword(s):  
Atrial Fibrillation ◽  
Coronary Artery ◽  
Current Literature ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulant ◽  
Dual Therapy ◽  
Bleeding Risk ◽  
Thrombotic Risk ◽  
Coronary Artery Stenting ◽  
Short Period

Abstract Purpose Updates to the primary literature and clinical practice guidelines on use of antithrombotic combinations for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) and stenting are reviewed. Summary Up to 8% of patients undergoing PCI have AF and thus require both antiplatelet and anticoagulation therapies, which put them at increased risk for bleeding. Current literature suggests that using a single antiplatelet agent in combination with oral anticoagulation with a direct-acting oral anticoagulant (i.e., dual therapy) is effective and associated with less bleeding risk than triple therapy (dual antiplatelet therapy plus an oral anticoagulant) in patients with AF undergoing PCI with stent placement. The most recently studied dual therapy regimens consist of clopidogrel in combination with apixaban, rivaroxaban, or dabigatran. Guidelines recommend use of an oral anticoagulant plus clopidogrel and aspirin for a short period of time. In general, aspirin should be discontinued in most patients at discharge. In patients with a high risk of thrombosis, aspirin can be continued for up to 1 month. Dual therapy should be continued for 12 months, with oral anticoagulant monotherapy continued thereafter. Conclusion A review of current literature on antithrombotic therapy in patients with AF undergoing PCI and subsequent coronary artery stenting indicates that the favored regimen is dual therapy consisting of clopidogrel with rivaroxaban, apixaban, dabigatran, or a vitamin K antagonist. Aspirin may be used in the periprocedural period but should be discontinued thereafter to reduce the risk of bleeding. Decisions regarding specific agents and duration of treatment should be based on thrombotic risk, bleeding risk, and patient preference.

Complex antithrombotic therapy and bleeding risk in patients with peripheral arterial disease

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Tseng ◽  
S Bhatt ◽  
M Girardo ◽  
D Liedl ◽  
P Wennberg ◽  
...  
Keyword(s):  
Peripheral Arterial Disease ◽  
Triple Therapy ◽  
Major Bleeding ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Arterial Disease ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Peripheral Arterial

Abstract Introduction Antiplatelet therapy is the cornerstone of treatment for many atherosclerotic vascular pathologies including peripheral arterial disease (PAD). Patients with PAD often have comorbid conditions that require complex antithrombotic therapy, i.e. combined antiplatelet and anticoagulation. Methods All adult patients undergoing ankle brachial index (ABI) measurements were included in the study. ABI values between 1.00 and 1.40 were considered normal, and values below 1.00 or above 1.40 were considered PAD. Demographic, comorbidity and outcome data were obtained using diagnostic codes from the electronic health record. Three medication classes were analyzed: aspirin, non-aspirin oral antiplatelets (e.g. P2Y12 inhibitors) and oral anticoagulants (warfarin and the direct oral anticoagulants). Medication use was determined for patients who had been on a medication for at least one year. Cox proportional hazard analysis for the time to first bleeding event was analyzed. Bleeding was defined as any bleeding requiring medical evaluation (including clinically-relevant non-major bleeding and major bleeding). Results In all, 40,144 patients were included in the analysis (mean age 66±15, 43% female). Patients with PAD were more likely to be on double therapy (one antiplatelet with anticoagulation) (28% vs 19%) and triple therapy (dual antiplatelet with anticoagulation) (10% vs 4%). Unadjusted hazard ratios for bleeding risk showed increased risk of bleeding for patients with PAD (1.18, 95% confidence interval [CI]: 1.08–1.29), though the association is no longer present after adjustment for antithrombotic therapy. Adjusting for age, sex and PAD class, compared to no antithrombotic therapy, there was increased risk of bleeding for monotherapy (1.91, 95% CI: 1.61–2.26), double therapy (3.40, 95% CI: 2.89–4.00) and triple therapy (5.00, 95% CI: 4.21–5.96). Among medications, aspirin and anticoagulant use was independently associated with the greatest increase in risk of bleeding. Conclusion Patients in PAD are at increased risk of bleeding secondary to antithrombotic therapy. Complex antithrombotic therapy with double or triple therapy confer additional bleeding risk, particularly regimens containing aspirin and oral anticoagulants. Funding Acknowledgement Type of funding source: None

scholarly journals Combination of Oral Anticoagulants and Single Antiplatelets versus Triple Therapy in Nonvalvular Atrial Fibrillation and Acute Coronary Syndrome: Stroke Prevention among Asians

2020 ◽  
Vol 29 (02) ◽  
pp. 088-097
Author(s):  
Anwar Santoso ◽  
Sunu B. Raharjo
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Triple Therapy ◽  
Stroke Prevention ◽  
Thrombus Formation ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Nonvalvular Atrial Fibrillation ◽  
Coronary Syndrome

AbstractAtrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)–vascular disease, age 65 to 74 years, sex category (female; CHA2DS2-VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, “triple therapy” comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for “triple therapy” would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.

scholarly journals Correction to: Antithrombotic therapy in atrial fibrillation: stop triple therapy and start optimizing dual therapy?

2019 ◽  
Vol 109 (1) ◽  
pp. 131-131
Author(s):  
Bernhard Wernly ◽  
Michael Lichtenauer ◽  
David Erlinge ◽  
Christian Jung
Keyword(s):  
Atrial Fibrillation ◽  
Triple Therapy ◽  
Antithrombotic Therapy ◽  
Dual Therapy

scholarly journals Novel Dual Therapy: A Paradigm Shift in Anticoagulation in Patients of Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

TH Open ◽  
2020 ◽  
Vol 04 (04) ◽  
pp. e332-e343
Author(s):  
Akshyaya Pradhan ◽  
Monika Bhandari ◽  
Pravesh Vishwakarma ◽  
Rishi Sethi
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Triple Therapy ◽  
Antiplatelet Therapy ◽  
Paradigm Shift ◽  
Oral Anticoagulants ◽  
Dual Therapy ◽  
Coronary Intervention ◽  
Bleeding Events ◽  
Percutaneous Coronary

AbstractPatients with atrial fibrillation (AF) on long-term oral anticoagulation (OAC) either have underlying coronary artery disease or suffer from acute coronary syndromes necessitating a percutaneous coronary intervention (PCI). In such a scenario, an amalgamation of antiplatelet and antithrombotic therapy (conventionally called as “triple therapy”) is obligatory for preventing coronary ischemia and stroke. But such ischemic benefits are accrued at the cost of increased bleeding. We also now know that bleeding events following PCI are related to increased mortality. Balancing the bleeding and ischemic risks is often a clinical dilemma. With the advent of novel oral anticoagulants (NOAC's) with preserved efficacy and attenuated bleeding rates, anticoagulation in AF is undergoing paradigm shift. The spotlight is now shifting from conventional triple therapy (vitamin-K antagonist + dual antiplatelet therapy [VKA + DAPT]) to novel dual therapy (NOAC + single antiplatelet therapy [SAPT]) in situation of anticoagulated AF patients undergoing PCI. Such a strategy aims to ameliorate the higher bleeding risk with conventional VKA's while retaining the ischemic benefits. In this review, we briefly discuss the need for combination therapy, trials of novel dual therapy, strategies for mitigating bleeding, the current guidelines, and the future perspectives in AF undergoing PCI with stent(s).

scholarly journals Triple Therapy When Thrombotic Risk Exceeds Bleeding Risk: Polycythemia Vera in a Patient With Atrial Fibrillation and Subacute Stent Thrombosis

2019 ◽  
Vol 10 (11) ◽  
pp. 315-318
Author(s):  
Elif Aksoy ◽  
Isaac Akkad ◽  
Giorgio Medranda ◽  
Anoop Titus ◽  
Ramesh Daggubati
Keyword(s):  
Atrial Fibrillation ◽  
Polycythemia Vera ◽  
Triple Therapy ◽  
Stent Thrombosis ◽  
Bleeding Risk ◽  
Thrombotic Risk

scholarly journals Dual therapy in a patient with atrial fibrillation at high risk of bleeding

ABOUTOPEN ◽  
2018 ◽  
Vol 4 (1) ◽  
pp. 104-109
Author(s):  
Andrea Rolandi
Keyword(s):  
Atrial Fibrillation ◽  
Triple Therapy ◽  
Oral Anticoagulant Therapy ◽  
Dual Therapy ◽  
Thrombotic Risk ◽  
Coronary Syndrome ◽  
Risk Of Bleeding ◽  
Hemorrhagic Events ◽  
The Individual ◽  
The Right

In patients with atrial fibrillation (AF) undergoing coronary angioplasty (PCI) the guidelines recommend the use of triple therapy (oral anticoagulant therapy in addition to dual antiplatelet therapy) for varying periods depending on the individual patient's risk profile, limiting the possibility of starting immediately with dual antithrombotic therapy to patients with relevant haemorrhagic risk. Triple therapy is associated with a high frequency of major bleeding; in recent years there have been several studies investigating new therapeutic strategies attempting to reduce the risk of bleeding without increasing the thrombotic risk. We report the case of an elderly patient suffering from hypertension, a previous acute coronary syndrome with anterior descending stenting and permanent AF treated with dabigatran 110 mg bid for 2 years. The patient is admitted to hospital for syncope with facio-brachio-crural hemiparesis associated with myocardial infarction; she is treated with idarucizumab and coronary angiography shows trivessel disease with acute occlusion of the right proximal coronary arteru. This case is an example of how in a patient with AF, in which the risk of bleeding increases 4-fold, the adoption of the dual therapy rather than the triple therapy immediately after the acute event (according to data from the RE-DUAL PCI) or after 1 month (according to the guidelines), can prove effective over the long term, ensuring adequate protection both from hemorrhagic events and from the risk of stent thrombosis (Cardiology).

scholarly journals The Complex Management of Atrial Fibrillation and Cancer in the COVID-19 Era: Drug Interactions, Thromboembolic Risk, and Proarrhythmia

2020 ◽  
Vol 17 (6) ◽  
pp. 365-383
Author(s):  
Milo Gatti ◽  
Emanuel Raschi ◽  
Elisabetta Poluzzi ◽  
Cristian Martignani ◽  
Stefania Salvagni ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Drug Interactions ◽  
Anticancer Agents ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Torsade De Pointes ◽  
Bleeding Risk ◽  
Qt Prolongation ◽  
Thrombotic Risk ◽  
Mortality And Morbidity

Abstract Purpose of Review Cardiotoxicity by anticancer agents has emerged as a multifaceted issue and is expected to affect both mortality and morbidity. This review summarizes clinical challenges in the management of oncological patients requiring anticoagulants for atrial fibrillation (AF) also considering the current outbreak of the COVID-19 (coronavirus disease 2019) pandemic, since this infection can add challenges to the management of both conditions. Specifically, the aims are manyfold: (1) describe the evolving use of direct oral anticoagulants (DOACs) in AF patients with cancer; (2) critically appraise the risk of clinically important drug-drug interactions (DDIs) between DOACs and oral targeted anticancer agents; (3) address expected DDIs between DOACs and candidate anti-COVID drugs, with implications on management of the underlying thrombotic risk; and (4) characterize the proarrhythmic liability in cardio-oncology in the setting of COVID-19, focusing on QT prolongation. Recent Findings AF in cardio-oncology poses diagnostic and management challenges, also due to the number of anticancer drugs recently associated with AF onset/worsening. Oral targeted drugs can potentially interact with DOACs, with increased bleeding risk mainly due to pharmacokinetic DDIs. Moreover, the vast majority of oral anticancer agents cause QT prolongation with direct and indirect mechanisms, potentially resulting in the occurrence of torsade de pointes, especially in susceptible patients with COVID-19 receiving additional drugs with QT liability. Summary Oncologists and cardiologists must be aware of the increased bleeding risk and arrhythmic susceptibility of patients with AF and cancer due to DDIs. High-risk individuals with COVID-19 should be prioritized to target preventive strategies, including optimal antithrombotic management, medication review, and stringent monitoring.

scholarly journals Atrial fibrillation patients undergoing percutaneous coronary intervention: dual or triple antithrombotic therapy with non-vitamin K antagonist oral anticoagulants

2020 ◽  
Vol 22 (Supplement_I) ◽  
pp. I22-I31
Author(s):  
Andreas Goette ◽  
Pascal Vranckx
Keyword(s):  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Triple Therapy ◽  
Vitamin K ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Coronary Intervention ◽  
Vitamin K Antagonist ◽  
Percutaneous Coronary ◽  
The Impact

Abstract About 20% of all atrial fibrillation (AF) patients develop coronary artery disease, which requires coronary stenting [percutaneous coronary intervention (PCI)]. Thus, this subcohort of AF patients may require aggressive antithrombotic therapy encompassing vitamin K antagonist (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) plus aspirin and a P2Y12 inhibitor. At present, four clinical Phase IIIb trials using dabigatran, rivaroxaban, apixaban, or edoxaban, were published. These studies assessed the impact of NOACs as a part of DAT therapy vs. triple therapy. Compared with triple therapy, NOAC-based DAT has been shown to be associated with reduced major bleeding as well as intracranial haemorrhages. The benefit, however, is somewhat counterbalanced by a higher risk of stent-related ischaemia during the early phase of dual therapy. Thus, triple therapy after stenting is appropriate for at least 14 days with a maximum of 30 days. Thereafter, DAT including a NOAC is the therapy of choice in AF PCI patients to reduce the risk of bleeding during a 1 year of follow-up compared to VKA-based regimes. The present review summarizes the published study results and demonstrates differences in trial design and reported outcomes.

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