Dry goods | EHJ debate: Should triple antithrombotic therapy be limited to 1 week in coronary stented patients with atrial fibrillation?

*For medical professionals only

“img class=”responsive ” sizes=”(min-width: 320px) 320px, 100vw” src=”https://mmbiz.qpic.cn/mmbiz_png/x5F5KAyDKw19I4VvcibrfNia7lD1fial5KribXqZxjxMxtoc3ichKKz6ib3w5kJias8QNRBYGn80MM0AxEgOvRLibqE2uw/640″ width=”6400″ >How best to treat atrial fibrillation (AF)combinedor acute coronary syndrome ( ACS)/Patients who had recently received a coronary stentimplantationextremely< /span>Challengesexual. In recent years, a lot of changes have taken place in the field of antithrombotic, cardiologists started Rethinking the intensity of antithrombotic therapy and trying to achieve a better balance of efficacy and safety.

Recently, the European Heart Journal published a heavy debate on whether triple antithrombotic therapy should be limited to 1 week in patients with atrial fibrillation with coronary stents ? “, let’s take a look.

Stent thrombosis (especially subacute thrombosis) is a bad predictor of poor stent treatment. Subacute thrombosis frequently occurs within 1 day to 1 month after PCI and is due to inadequate stent characteristics, length, diameter, location, and deployment, as well as patient-related factors.

To prevent stent thrombosis, two pioneering trials ( ISAR 2 and STARS3) were clearly established over dual antiplatelet therapy (DAPT, aspirin + P2Y12 inhibitor) in patients who had recently undergone stenting Oral anticoagulation regimen. On the other hand, patients with atrial fibrillation require anticoagulation (eg, warfarin) to prevent stroke. In ACTIVE-W, investigators attempted to compare aspirin plus clopidogrel with warfarin in preventing stroke in atrial fibrillation, but apparently Warfarin was more effective and had similar rates of major bleeding.

Therefore,stenting and atrial fibrillation require two different antithrombotic approaches, and when both are present When a dilemma arises. For many years, cardiologists, primarily concerned with thrombosis, embraced the “triple therapy (TT)” dogma, in this case simply combining aspirin, clopidogrel, and antifungal drugs The coagulants are stacked. The initial default duration was set to 1 year, after which the risk of stent thrombosis (requiring DAPT) was considered to have been substantially reduced.

The antithrombotic situation has changed a lot in recent years. These include:

P2Y12 inhibitors (prasugrel and ticagrelor) that demonstrate pharmacokinetically more potent Stronger and longer-lasting platelet inhibition than clopidogrel, thus becoming the default antiplatelet strategy after ACS. · Introduction of non-VKA oral anticoagulants (NOACs, direct oral anticoagulants) reduces major bleeding (especially intracranial hemorrhage) and reduces 10% mortality rate. · Recognizing that TT is a threat in terms of bleeding, it is estimated that 20-30% of clinically relevant bleeding occurs annually, approximately 40% higher than DAPT. %. · Recognizing that bleeding can be as severe as repeated ischemic events, and that actual recurrences of ischemic events often result from a variety of causes, The most relevant is probably the abrupt interruption of antithrombotic therapy (sometimes even with minor bleeding). Introduction of more modern stent platforms, it has been reported that even a very short duration of DAPT (<3 months) followed by inhibition of P2Y12 , is also the treatment of choice to reduce major bleeding and myocardial infarction.

Cardiologists are starting to rethink this dogma, reducing the intensity of antithrombotic therapy in an attempt to achieve a better balance of efficacy and safety< /strong>.

·  WOEST trialsin relative numbers In a small number of stented patients with ACS or chronic coronary syndrome, reduction of one component of a combined antithrombotic regimen (ie, aspirin) was actually associated with lower mortality compared with standard TT. The study also linked less bleeding on dual antithrombotic therapy (DAT, clopidogrel plus VKA) with lower mortality, as deaths were concentrated in patients with bleeding.

The reason for giving up aspirin (instead of clopidogrel) is also a matter of debate.

Recent PCI without atrial fibrillationTrials in populations showed an overall advantage (the composite primary outcome of readmissions due to ACS, ischemic and bleeding events) using aspirin instead of clopidogrel, but here the use of All-cause mortality (the non-primary endpoint) was numerically higher with clopidogrel instead of aspirin, with similar trends for cardiac and noncardiac deaths.

However, industry consensus soon emerged to use a combination of anticoagulants and P2Y12 inhibitors in these patients.

Four pivotal trials comparing NOAC and VKA< /strong>Consistently showed that this DAT strategy had a better efficacy-to-safety ratio than classic TT, but this was mainly due to two antithrombotic drugs (rather than three drugs) ) significantly reduced bleeding.

The use of NOACs (rather than VKAs) is certainly an advantage; therefore, in such patients, the use of DATs one year after stenting ( NOAC and P2Y12 inhibitors) have become the “new dogma”. Temporarily withholding anticoagulants, especially in patients at low to moderate stroke risk, an alternative to DAPT (prasugrel/ticagrelor instead of clopidogrel) has not been formally validated .

If the DAT regimen is chosen and the aspirin+P2Y12 inhibitor regimen is abandoned to prevent stent thrombosis, how long does it take? Can it be implemented safely?

As early as 2015, the European Heart Rhythm Association (EHRA) guidelines recommended that acute coronary syndrome In patients with atrial fibrillation, the initial default TT after PCI was 6 months, adjusted for ischemia and bleeding risk. ·  Recently, European Society of Cardiology (ESC) guidelines and EHRA guidelines reduce this time to 1 month or even 1 week.

This latest extreme position estimates that, in most patients, the risk of stent thrombosis with current-generation drug-eluting stents attenuates prematurely to the point that safety concerns allow early discontinuation aspirin. However, some cardiologists are uncomfortable with such extreme shortening of TT time, arguing that there is a higher risk of cardiac ischemic events, primarily stent-related ischemic events.

All guidelines and consensus documents emphasize that TT duration is tailored to the individual patient, but “standards” and The standard question of “default” duration is relevant because most cardiologists will use it as a reference for most patients.

In the form of debate, the two groups of researchers in this paper have decided on the best default for TT after stent implantation in patients with acute coronary syndrome and atrial fibrillation. Up-to-date recommendations for duration are given for or against.

The reader should see the pros and cons of these two different positions, and in the difficult practice of this “precision medicine”, there are Intermediate grey area. Understanding the context of these two perspectives, in the difficult navigating between the dilemma of thrombosis and bleeding, helps to properly manage the various situations encountered.


Great Debate: Triple antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting should be limited to 1 week. Eur Heart J. 2022;ehac294. doi: 10.1093/eurheartj/ehac294.

< strong>Recommended Reading

Interpretation of Heart Failure Guidelines | 2021 ESC and 2022 ACC/AHA/HFSA Guidelines Recommendations Comparison

Effect of early oral β-blockers on reducing the risk of major bleeding in hospitalized patients with ACS——Analysis of the latest Chinese CCC-ACS research

Progress | Can gua+sacubitril/valsartan better improve the prognosis of HFrEF? VICTORIA Trial Results Announced

Progress | JAMA Blockbuster: Can Omecamtiv Mecarbil, a Cardiac Myosin Activator, Improve Exercise Performance in Chronic HFrEF?

Progress | Does CMR have additional value in assessing left ventricular remodeling in the prognosis of chronic aortic regurgitation?

Progress| Atrial fibrillation complicated with intracranial hemorrhage, the efficacy and safety of antithrombotic therapy

Progress| Preclinical cardiology in community population Incidence of failure

Progress | SGLT2i dapagliflozin, is it equally safe and effective under different concomitant medication backgrounds?

Progress | CETP inhibitor dalcetrapib in ACS: a pharmacogenetics-guided trial

Progress| JACC: manifestations of atrial fibrillation Form, prognosis of early rhythm control

progress|incidence and determinants of disease progression in paroxysmal atrial fibrillation

dry goods| JACC heavy LB: coronary in-stent restenosisprogress | Circulation: The effect of patient-reported preoperative physical and mental health on 10-year mortality of coronary revascularization

Progress | Lancet Blockbuster: Moderate-intensity statin + ezetimibe vs. high-intensity statin monotherapy, which is more suitable for long-term treatment of ASCVD?

Progress | When should dedicated palliative care be initiated in patients with end-stage heart failure?

© 2021 All Rights Reserved. Design & Developed By Besticoder