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.
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