Anti-thromboembolic strategies in atrial fibrillation

Abstract

Oral anticoagulation (OAC) is highly effective for stroke prevention in high-risk-patients with atrial fibrillation (AF). AF is also a risk for dementia, and effective OAC reduces the risk of dementia. Up to 30% of patients with AF have a coronary artery disease and antiplatelets are used to avoid thrombotic complications. Patients with AF often have an acute coronary syndrome (ACS) and undergo a percutaneous intervention with stent-implantation. These patients require a triple therapy, i.e. the combination of OAC with dual-antiplatelet therapy. It is obvious that OAC may induce bleeding with potentially deleterious effects on mortality. Even the occurrence of minor bleeding is problematic.

The review describes available data on used anti-thromboembolic regimens in patients treated with OAC (vitamin K antagonists and non-vitamin K antagonists) who need a triple therapy (i.e. anticoagulation and antiplatelets). Most data are from patients who were treated for an ACS and cannot be directly extrapolated for patients with AF. The impact of used stents and novel P2Y12 antagonist-antiplatelets and duration of triple therapy is discussed. Often some high-risk patients with AF would need anticoagulation but cannot be given this therapy be­cause of excessive bleeding risks or contraindicating comorbidities: in these patients left atrial appendage closure with an occluding device can be used as an alternative to anti-thromboem­bolic therapy.

The unavoidable anti-thromboembolic triple therapy carries a strong potential for bleeding events, which increase mortality. We have many data and several recommendations are offered. Nonetheless, we lack solid data on the best anti-thromboembolic regimen in patients with AF who need anticoagulation and antiplatelets.