Antithrombotic treatment in atrial fibrillation patients needing percutaneous coronary intervention

Abstract

Patients with nonvalvular atrial fibrillation (AF) need chronic with by non-vitamin K oral anticoagulants (NOACs) or vitamin K antagonists [1]. NOACs are more convenient to use and have a larger net clinical benefit than vitamin K antagonists. While this development has simplified anticoagulant management in these patients, it is different for AF patients needing coronary interventions. It is estimated that, at some time, around 20% of patients with AF require percutaneous coronary intervention (PCI) and subsequent antiplatelet therapy. While guidelines contain class I recommendations for the default immediate periprocedural and postPCI antithrombotic therapy, as well as postdischarge up to 12 months, there is less certainty, about the same antithrombotic therapy regimens in patients on NOACs who have a high bleeding risk, a high ischaemic risk or both (see Fig. 8 in Collet et al. [2]). These uncertainties are displayed in the article by De Veer and colleagues in this issue of the Netherlands Heart Journal [3]. In an international survey among interventional cardiologists, most of whom were working in a Dutch hospital, the authors asked about the antithrombotic management of two hypothetical patients with AF: one patient using a standard dose of a NOAC who presents with an acute non-STelevation myocardial infarction (NSTEMI) and requires PCI with stenting and another patient using a standard dose of a NOAC who needs to undergo elective PCI. While the authors concluded that there was heterogeneity in the management strategy among the interventional cardiologists, reflecting the guidelines, there