Think before you prescribe - Consider dual therapy in patients with atrial fibrillation undergoing PCI and stenting

Dual antiplatelet therapy (DAPT), with aspirin and clopidogrel for 6-12 months, is usual after percutaneous coronary intervention (PCI) to prevent stent thrombosis and major adverse cardiac events (MACE) (J Thorac Cardiovasc Surg. 2016;152:1243-75). Because these patients are already on warfarin, an anti-Xa inhibitor (rivaroxaban or apixaban) or a direct thrombin inhibitor (dabigatran) as they have a separate indication for atrial fibrillation (AF), they are therefore subject to triple antiplatelet therapy increasing their risk of serious bleeding complications.

Data from the WOEST (What is the Optimal AntiplatElet and Anticoagulant Therapy in Patients With Oral Anticoagulation and Coronary StenTing) trial conducted in 15 centers in Belgium and the Netherlands show that compared with triple therapy, use of clopidogrel without aspirin was associated with a significant reduction in bleeding complications and no increase in the rate of thrombotic events. Bleeding episodes were seen in 19.4% patients receiving double therapy and in 44.4% receiving triple therapy (Lancet. Mar 30; 2013;381:1107-15).

A recently published systematic review and meta-analysis of four randomized clinical trials also concluded that dual antithrombotic may be a better option than triple antithrombotic therapy in many AF patients post-PCI. A reduction of 47% was noted in Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding with dual therapy in comparison to triple therapy (Eur Heart J. 2018 May 14;39:1726a-35a).

Trials like the RE-DUAL PCI (N Engl J Med. 2017 Oct 19;377(16):1513-1524) and PIONEER AF-PCI (N Engl J Med. 2016 Dec 22;375(25):2423-2434) further support the use of dual therapy in AF patients undergoing PCI with stent placement.

Another caution that must be exercised in these patients is with regard to the use of NSAIDs. A post hoc analysis of NSAIDs in the RE-LY (Randomized Evaluation of Long Term Anticoagulant Therapy) trial has shown an association of NSAIDs with increased risk of major bleeding, stroke/SE, and hospitalization in AF patients (J Am Coll Cardiol. 2018 Jul 17;72(3):255-267).

Consider dual therapy in your patients with AF undergoing PCI with stent placement to prevent stent thrombosis and bleeding complications.