Triple antithrombotic therapy in patients with atrial fibrillation undergoing coronary artery stenting: hovering among b
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REVIEW
Open Access
Triple antithrombotic therapy in patients with atrial fibrillation undergoing coronary artery stenting: hovering among bleeding risk, thromboembolic events, and stent thrombosis Mila Menozzi1*, Andrea Rubboli2, Antonio Manari1, Rossana De Palma3 and Roberto Grilli3
Abstract Dual antiplatelet treatment with aspirin and clopidogrel is the antithrombotic treatment recommended after an acute coronary syndrome and/or coronary artery stenting. The evidence for optimal antiplatelet therapy for patients, in whom long-term treatment oral anticoagulation is mandatory, is however scarce. To evaluate the safety and efficacy of the various antithrombotic strategies adopted in this population, we reviewed the available evidence on the management of patients receiving oral anticoagulation, such as a vitamin-k-antagonists, referred for coronary artery stenting. Atrial fibrillation is the most frequent indication for oral anticoagulation. The need of starting antiplatelet therapy in this clinical scenario raises concerns about the combination to choose: triple therapy with warfarin, aspirin, and a thienopyridine being the most frequent and advised. The safety of this regimen appeared suboptimal because of an increased risk in hemorrhagic complications. On the other hand, the combination of oral anticoagulation and an antiplatelet agent is suboptimal in preventing thromboembolic events and stent thrombosis; dual antiplatelet therapy may be considered only when a high hemorrhagic risk and low thromboembolic risk are perceived. Indeed, the need for prolonged multiple-drug antithrombotic therapy increases the bleeding risks when drug eluting stents are used. Since current evidence derives mainly from small, single-center and retrospective studies, large-scale prospective multicenter studies are urgently needed. Keywords: Atrial fibrillation, Percutaneous coronary intervention, Stent, Warfarin, Antiplatelet drugs
Introduction Long-term oral anticoagulation (OAC) with vitamin K antagonists is recommended in patients with atrial fibrillation (AF) at moderate to high risk of stroke, those with prosthetic heart valves, previous cardiogenic thromboembolism, recent deep vein thrombosis or pulmonary embolism [1-3]. In the event that also an indication for dual antiplatelet therapy (DAPT) arises, mainly because of percutaneous coronary intervention with stent implantation (PCI-S) [4], the management of these patients becomes * Correspondence: [email protected] 1 Interventional Cardiology, S. Maria Nuova Hospital; Viale Risorgimento, 80 42123 Reggio Emilia, Italy Full list of author information is available at the end of the article
challenging. It is estimated that about 5% of patients undergoing percutaneous coronary interventions (PCI) has atrial fibrillation or other indications for chronic oral anticoagulant therapy [5]. Since DAPT provides insufficient protection against stroke and thrombotic complications in patients with AF and mechanical aortic valves [6,7], substitution of OAC with DAPT appears not applica
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