Abstract
A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12inhibitor, preferably clopidogrel, in combination with a non-vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.
| Original language | English |
|---|---|
| Pages (from-to) | 583-596 |
| Number of pages | 14 |
| Journal | Circulation |
| Volume | 143 |
| Issue number | 6 |
| DOIs | |
| State | Published - Feb 9 2021 |
Bibliographical note
Publisher Copyright:© 2021 Lippincott Williams and Wilkins. All rights reserved.
Funding
OrbusNeich, Osprey Medical, PLC/RenalGuard, and Abbott Vascular; grant support and advisory board fees, paid to her institution, from BMS; fees for serving on a data and safety monitoring board from Watermark Research Funding; advisory fees and lecture fees from Medintelligence (Janssen); and lecture fees from Bayer. Dr Moliterno reports no disclosures. Dr Price reports consulting/ advisory board fees and honoraria from Abbott Vascular, AstraZeneca, Boston Scientific, Chiesi USA, Medtronic, and W.L. Gore Medical, and grants (to his institution) from Daiichi Sankyo. Dr Saw has received unrestricted research grant supports from the Canadian Institutes of Health Research, Heart & Stroke Foundation of Canada, National Institutes of Health, AstraZeneca, Abbott Vascular, St Jude Medical, Boston Scientific, and Servier; salary support from Michael Smith Foundation for Health Research; speaker honoraria from AstraZen-eca, Abbott Vascular, Boston Scientific, and Bayer; consultancy and advisory board honoraria from AstraZeneca, Boston Scientific, Abbott Vascular, Gore, Abiomed, and Baylis; and proctorship honoraria from Abbott Vascular and Boston Scientific. Dr Tanguay has received consulting fees or honoraria from Abbott, AstraZeneca, Bayer, Biosensors, Bristol Myers Squibb/Pfizer Alliance, Dai-ichi-Sankyo, Novartis, and Servier; and his institution has received research grants from Abbott Vascular, AstraZeneca, Biosensors, Idorsia, and Novartis. Dr Angiolillo has received consulting fees or honoraria from Abbott, Amgen, Aralez, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, PhaseBio, PLx Pharma, Pfizer, Sanofi, and The Medicines Company; has received payments for participation in review activities from CeloNova and St Jude Medical; and his institution has received research grants from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Idorsia, Janssen, Matsutani Chemical Industry Co, Merck, Novartis, Osprey Medical, Renal Guard Solutions, and the Scott R. MacKenzie Foundation. Dr Bhatt discloses the following relationships: advisory board: Cardax, CellPro-thera, Cereno Scientific, Elsevier Practice Update Cardiology, Level Ex, Med-scape Cardiology, PhaseBio, PLx Pharma, and Regado Biosciences; board of directors: Boston VA Research Institute, Society of Cardiovascular Patient Care, and TobeSoft; chair: American Heart Association Quality Oversight Committee; data monitoring committees: Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for PORTICO [Portico Re-sheathable Transcath-eter Aortic Valve System US IDE Trial], funded by St Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial [ExCEED: Centera THV System in Intermediate Risk Patients Who Have Symptomatic, Severe, Calcific, Aortic Stenosis], funded by Edwards), Contego Medical (Chair, PERFORMANCE-II [Protection Against Emboli During Carotid Artery Stenting Using the Neuroguard IEP System]), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial [Edoxaban Compared to Standard Care After Heart Valve Replacement Using a Catheter in Patients With Atrial Fibrillation], funded by Daiichi-Sankyo), and Population Health Research Institute; honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice-Chair, American College of Cardiology Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; REDUAL-PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II [Study to Investigate CSL112 in Subjects With Acute Coronary Syndrome] executive committee funded by CSL Behring), Bel-voir Publications (Editor-in-Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for PRONOUNCE [A Trial Comparing Cardiovascular Safety of Degarelix Versus Leuprolide in Patients With Advanced Prostate Cancer and Cardiovascular Disease], funded by Ferring Pharmaceuticals), HMP Global (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS [Cardiovascular Outcomes for People Using Anticoagulation Strategies] operations committee, publications committee, steering committee, and US national coleader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), and WebMD (CME steering committees); other: Clinical Cardiology (Deputy Editor), National Cardiovascular Data Registry ACTION Registry Steering Committee (Chair), VA Clinical Assessment, Reporting and Tracking Program Research and Publications Committee (Chair); research funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regen-eron, Roche, Sanofi Aventis, Synaptic, and The Medicines Company; royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); site coinvestigator: Biotronik, Boston Scientific, CSI, St Jude Medical (now Abbott), and Svelte; trustee: American College of Cardiology; and unfunded research: FlowCo, Merck, Novo Nordisk, and Takeda. Dr Cannon reports research grants from Amgen, Boehringer-Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, Janssen, Merck, and Pfizer; and consulting fees from Aegerion, Alnylam, Amarin, Amgen, Applied Therapeutics, Ascendia, BI, BMS, Corvidia, Eli Lilly, HLS Therapeutics, Innovent, Janssen, Kowa, Merck, Pfizer, Sanofi, and Rhoshan. Dr Eikelboom reports honoraria and/or research support from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi-Sankyo, Janssen, Pfizer, and Servier. Dr Faxon reports support from Boston Scientific, Medtronic, Highlife Medical, Otsuka, Surmodics, and Conformal. Dr Gibson receives research funds from Janssen and Johnson & Johnson and consulting funds from Janssen, Johnson & Johnson, and Bayer. Dr Goodman reports research grant support (eg, steering committee or data and safety monitoring committee) and/or speaker/consulting honoraria (eg, advisory boards) from: Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CSL Behring, Daiichi-Sankyo/American Regent, Eli Lilly, Esperion, Ferring Pharmaceuticals, GlaxoSmithKline, HLS Therapeutics, Janssen/Johnson & Johnson, Merck, Novartis, Novo Nordisk A/C, Pfizer, Regeneron, Sanofi, and Servier; and salary support/honoraria from the Heart and Stroke Foundation of Ontario/University of Toronto (Polo) Chair, Canadian Heart Research Center and MD Primer, Canadian VIGOUR Center, Duke Clinical Research Institute, New York University Clinical Coordinating Center, and PERFUSE Research Institute. Dr Granger reports research grant support from AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol Meyers Squibb, GlaxoSmithKline, Medtronic Foundation, Daiichi Sankyo, Janssen Pharmaceuticals, Bayer, Pfizer, Novartis, Population Health Research Institute, US Food and Drug Administration, and National Heart, Lung, and Blood Institute; and consulting fees from Boehringer-Ingelheim, Boston Scientific, Bristol Meyers Squibb, CeleCor Therapeutics, GlaxoSmithKline, Eli Lilly, Medtronic Foundation, Merck & Co, Novartis, Pfizer, Daiichi Sankyo, Rho Pharmaceuticals, Verseon, and Janssen Pharmaceuticals. All current conflicts of interest are listed at https://dcri.org/about-us/conflict-of-interest/. Dr Holmes reports no disclosures. Dr Lopes reports grants and personal fees from Bristol Myers Squibb and Pfizer, personal fees from Boehringer Ingelheim and Bayer AG, and grants from Amgen Inc, GlaxoSmithKline, Medtronic PLC, and Sanofi Aventis outside the submitted work. Dr Mehran reports receiving consulting fees from Abbott Vascular, Boston Scientific, Medscape/WebMD, Siemens Medical Solutions, Phillips/Volcano/Spectranetics, Roviant Sciences, Sanofi Italy, Bracco Group, Janssen, and AstraZeneca; grant support, paid to her institution, from Bayer, CSL Behring, DSI, Medtronic, Novartis Pharmaceuticals,
| Funders | Funder number |
|---|---|
| Aegerion | |
| Alnylam Pharmaceuticals | |
| Canadian Heart Research Center | |
| CeloNova | |
| Duke Clinical Research Institute, New York University | |
| Heart and Stroke Foundation of Ontario/University | |
| Janssen/Johnson & Johnson | |
| Novo Nordisk A/S | |
| PERFUSE Research Institute | |
| Population Health Research Institute | |
| National Institutes of Health (NIH) | |
| U.S. Food and Drug Administration | |
| National Heart, Lung, and Blood Institute (NHLBI) | |
| Boehringer-Ingelheim | |
| Abbott Laboratories | |
| AMGen | |
| Bristol-Myers Squibb | |
| Eli Lilly and Company | |
| Pfizer | |
| AstraZeneca | |
| GlaxoSmithKline | |
| Merck | |
| Novartis | |
| Medtronic | |
| Heart and Stroke Foundation of Canada | |
| Gilead Sciences | |
| St. Jude Medical Center | |
| Chiesi Farmaceutici S.p.A. | |
| CSL Behring GmbH | |
| Boston Scientific Corporation | |
| Janssen Pharmaceuticals | |
| Abbott Vascular | |
| Medicines Company | |
| Bayer Fund | |
| HDL Therapeutics | |
| Scott R. MacKenzie Foundation | |
| Medtronic Foundation | |
| Canadian Institutes of Health Research | |
| Michael Smith Foundation for Health Research | |
| Daiichi Sankyo Company, Limited | |
| Eisai | |
| Institut de Recherches Servier |
Keywords
- anticoagulants
- antiplatelets
- atrial fibrillation
- stents
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine
- Physiology (medical)