Aspirin, Clopidogrel, DOAC, Warfarin: What Combination after PCI in Patients with AF?

Patients with atrial fibrillation (AF), who meet the indication for oral anticoagulation (ie, CHA₂DS₂-VASC ≥2), and have concomitant coronary artery disease (CAD) with an indication for percutaneous coronary intervention (PCI) (which necessitates the use of dual anti-platelet therapy) continue to pose an important clinical challenge for physicians. It is not at all unusual for clinicians to be left wondering which combination of the following drugs provides the greatest efficacy for these patients along with the lowest risk for bleeding: aspirin, clopidogrel, a direct-acting anticoagulant (DOAC), and warfarin.

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There is a contemporary strategy among physicians for patients with AF and CAD to use “triple therapy” (aspirin, clopidogrel, and oral anticoagulation) for a short period of time following PCI, then drop the aspirin and use only clopidogrel and oral anticoagulation for the duration of the required antiplatelet therapy.

References

1. Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013 30;381 (9872):1107-15. doi: 10.1016/S0140-6736(12)62177-1. Epub 2013 Feb 13

2. Dans AL, Connolly SJ, Wallentin L, et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation. 2013;127:634-640.

3. Cannon CP, Bhatt DL, Oldgren J, et al for the RE-DUAL PCI Steering Committee and Investigators. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. NEJM. Published online August 27, 2017. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa1708454#t=article