It has been an ongoing clinical challenge to decide how many antithrombotic agents—and which ones—to prescribe patients with atrial fibrillation (AFib) following percutaneous coronary intervention (PCI).
But a new North American consensus statement published July 30 in Circulation hopes to simply the issue, suggesting a non-vitamin K antagonist oral anticoagulant (NOAC) and the P2Y12 inhibitor clopidogrel should suffice in most cases. A triple therapy approach, in which aspirin is added to the equation, should only be considered for patients at high thrombotic risk and low bleeding risk—and only then for a short period of time.
“The consistency of significantly lower risk of bleeding with double therapy across major trials argues against the use of a triple-therapy regimen,” wrote the expert committee, led by Dominick J. Angiolillo, MD, PhD, with the University of Florida College of Medicine.
This lower bleeding risk with double therapy didn’t come at the expense of efficacy during two recent trials—PIONEER AF-PCI and RE-DUAL PCI—the authors noted. Based on these results, they published the update to their 2016 North American consensus statement.
Among the specific recommendations:
- A NOAC should be the anticoagulant of choice, whereas the 2016 guidelines said the anticoagulant could be up to the discretion of the physician and include vitamin K antagonist oral anticoagulants such as warfarin.
- Clopidogrel is the P2Y12 inhibitor of choice, but ticagrelor may represent a “reasonable” option for patients at high ischemic/thrombotic risk but low bleeding risk. Prasugrel should be avoided, the authors said. Evidence demonstrates prasugrel and ticagrelor are both more potent than clopidogrel but pose higher bleeding risks.
- NOAC dosing should be consistent with what was delivered in the trials of PCI for AFib patients.
- Physicians can stop antiplatelet therapy with clopidogrel 12 months post-PCI in most patients. But in patients at a high risk of bleeding, the drug can be cut off at six months.
Angiolillo et al. said the lack of head-to-head data comparing NOACs limits the ability to select a drug of choice in that category. The experts noted their document offers a “pragmatic approach” for managing this patient population but doesn’t represent a guideline because it isn’t endorsed by a cardiovascular society.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.