Antithrombotic Treatment in Patients With Atrial Fibrillation and Acute Coronary Syndromes

Results of the European Heart Rhythm Association Survey

Deirdre A. Lane; Nikolaos Dagres; Gheorghe-Andrei Dan; Javier García Seara; Konstantinos Iliodromitis; Radoslaw Lenarczyk; Gregory Y.H. Lip; Jacques Mansourati; Francisco Marín; Daniel Scherr; Tatjana S. Potpara

Disclosures

Europace. 2019;21(7):1116-1125. 

In This Article

Abstract and Introduction

Abstract

The management of an acute coronary syndrome (ACS) in a patient with existing atrial fibrillation (AF) often presents a management dilemma both in the acute phase and post-ACS, since the majority of AF patients will already be receiving oral anticoagulation (OAC) for stroke prevention and will require further antithrombotic treatment to reduce the risk of in-stent thrombosis or recurrent cardiac events. Current practice recommendations are based largely on consensus option as there is limited evidence from randomized controlled trials. Prior to the launch of the new European Heart Rhythm Association (EHRA) consensus document, a survey was undertaken to examine current clinical management of these patients across centres in Europe. Forty-seven centres submitted valid responses, with the majority (70.2%) being university hospitals. This EHRA survey demonstrated overall the management of ACS in AF patients is consistent with the available guidance. Most centres would use triple therapy for a short duration (4 weeks) and predominantly utilize a strategy of OAC (vitamin K antagonist, VKA or non-vitamin K antagonist oral anticoagulant, NOAC) plus aspirin and clopidogrel, followed by dual therapy [(N)OAC plus clopidogrel] until 12 months post-percutaneous coronary intervention, followed by (N)OAC monotherapy indefinitely. Where NOAC was used in combination with antiplatelet(s), the lower dose of the respective NOAC was preferred, in accordance with current recommendations.

Introduction

Acute coronary syndrome (ACS) commonly occurs in patients with atrial fibrillation (AF), which often requires percutaneous coronary intervention (PCI) typically including stenting. However, the occurrence of ST-segment elevation myocardial infarction (STEMI) or a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in a patient with existing AF often presents a management dilemma both in the acute phase and post-ACS, since the majority of AF patients will likely already be receiving oral anticoagulation (OAC) for stroke prevention and will require further antithrombotic treatment (ATT) to reduce the risk of in-stent thrombosis or recurrent cardiac events. This requires a delicate balancing of the risk of thromboembolic and atherothrombotic events against the increased chance of bleeding, and should be undertaken on an individual patient basis.[1,2]

In 2014, a joint consensus document was published to provide guidance on the management of ATT in AF patients presenting with ACS and/or undergoing PCI[3] in the setting of limited available evidence from randomized controlled trials (RCTs) about the optimal antithrombotic strategy post-ACS in patients with AF. Since 2014, further observational studies and RCT data has been published and non-vitamin K antagonist oral anticoagulants (NOACs) are more commonly used. In addition, there are more recent European guidelines on the management of AF[4] and management of STEMI,[5] focused updates on dual antiplatelet therapy in coronary artery disease[6] and the European Heart Rhythm Association (EHRA) NOAC practical guide[7] (which includes a chapter on the management of AF in patients with coronary artery disease). Therefore, the 2014 consensus guidance on the management of AF patients with ACS was updated in 2018[8] and EHRA conducted a survey to capture the current management of ACS in AF patients in Europe prior to the launch of the new consensus document.

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