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New Guidelines Reshape Approach to Antithrombotic Therapy

Around 1 in 4 individuals will develop atrial fibrillation (AF) during their lifetime, a development that increases their risk of stroke four- to five-fold. For most patients with AF, treatment with oral anticoagulant (OAC) therapy is associated with significantly lower stroke rates compared with aspirin or placebo.

Like AF, venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, has a high overall incidence estimated to be 1 to 2 per 1,000 person-years and is usually treated with OAC as well. Choosing the optimal antithrombotic regimen for patients with atherosclerotic cardiovascular disease and concomitant AF or VTE who require an anticoagulant and antiplatelet therapy can be a challenge for clinicians.

This 2020 Expert Consensus Decision Pathway (ECDP) aims to fill the gap for much-needed guidance on antithrombotic therapy for this patient population.

This ECDP highlights that patients with either AF or VTE undergoing percutaneous coronary intervention have usually been treated with an anticoagulant and dual antiplatelet therapy, so-called “triple therapy.” Support for this practice came from older clinical trials that suggested an OAC alone was not an optimal treatment for those undergoing percutaneous coronary intervention and, similarly, that dual antiplatelet therapy was not an optimal treatment for AF or VTE. However, triple antithrombotic therapy significantly increases the risk of bleeding and the writing committee for this document recommends against the routine use of triple antithrombotic therapy for most patients.

Because major bleeding is associated with as much as a five-fold increased risk of death following an acute coronary syndrome, the writing committee for this document found it imperative to identify the optimal antithrombotic therapy for patients with atherosclerotic cardiovascular disease and concomitant AF or VTE requiring an anticoagulant. The goal of antithrombotic therapy for these patients is to maintain antithrombotic efficacy while mitigating bleeding.

This ECDP provides guidance and recommendations for the best antithrombotic therapy regimen in this patient population.

The “2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease” is published online in the Journal of the American College of Cardiology.

— Source: American College of Cardiology