European Heart Journal Advance Access originally published online on October 30, 2006
European Heart Journal 2006 27(23):2909-2910; doi:10.1093/eurheartj/ehl349
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The combination of anticoagulant and anti-platelet therapy in patients with atrial fibrillation: a comment on the recent ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: reply
University Clinic San Carlos
Madrid
Spain
Hospital Clínico San Carlos
Instituo Cardiovascular
C/ Profesor Martín Lagos s/n
Madrid 28040
Spain
E-mail address: jlzamorano{at}vodafone.es
University Clinic San Carlos
Madrid
Spain
We appreciate your comment on the recommendations about anticoagulation in patients with atrial fibrillation (AF) who have undergone PCI. First, it is important to note that these statements appear in the recently published guidelines as a class IIb recommendation (level of evidence C). Since there are no prospective, randomized clinical trials specifically designed to address this issue, they are supported by the weakest level of evidence (consensus opinion of experts).1 Nevertheless, there are some important considerations.
The aim of practice guidelines is to guide the treatment of ‘day-to-day’ patients. Those recommendations are drawn from clinical trials, which sometimes included patients who may have different characteristics of patients seen in clinical practice. In relation to the design of these studies about antithrombotic treatment, there are two relevant factors: age and duration of follow-up.
Age is a well-known risk factor for bleeding complications, which is the most feared adverse event related to long-term antithrombotic treatment.1 It is known that AF and coronary artery disease are age-related conditions, which implies that most patients with chronic AF undergoing PCI will be at an increased risk of bleeding because of advanced age. However, a large proportion of clinical trials excluded elderly patients. Observational studies can provide useful information about the characteristics and outcome of these patients. In a retrospective study that included 66 patients discharged on triple therapy after PCI, the mean age was 75 years, and almost 40% of patients received anticoagulation for chronic AF2 and 10% of them required medical attention because of bleeding complications, which seems superior to that of clinical trials.2 In a cohort study of patients admitted with a primary or secondary diagnosis of AF, the mean age was 78.8 years and more than two-thirds were 
75 years of age.3
Oral anticoagulation has resulted to be more effective than aspirin in the prevention of thrombo-embolic events in patients with AF, and it also appears superior to the combination of aspirin and clopidogrel.1 Moreover, different studies suggest that anticoagulation in monotherapy (target INR around 3) is superior to aspirin alone in the prevention of death, re-infarction, and stroke in patients after myocardial infarction.4,5 Thus, anticoagulation is a good alternative to prevent both recurrent ischaemic events in patients with coronary heart disease and thrombo-embolic complications in patients with AF.
Taking into account the risks of acute thrombosis after PCI, it seems reasonable to add antiaggregation at least until endothelization has completed. In this setting, the combination of warfarin and aspirin was found less effective than the administration of aspirin and clopidogrel.2 As the triple therapy could be associated to a disproportionated increase in the risk of bleeding, it has been proposed to add clopidogrel to anticoagulation because of its effectiveness and the lack of gastroerosive action (main site of bleeding).6
Once more, it is important to consider that the selection of antithrombotic treatment should be based on a proper assessment of risks and benefits. Long-term combined antithrombotic treatment in this subgroup of patients seems to be a matter of safety more than a matter of efficacy.
References
- Fuster V, Rydén L, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey J, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S. (2006) ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force for Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol 48:149–246.
- Orford JL, Fasseas P, Melby S, Burger K, Steinhubl SR, Holmes DR, Berger PB. (2004) Safety and efficacy of aspirin, clopidogrel, and warfarin after coronary stent placement in patients with an indication for anticoagulation. Am Heart J 147:463–467.[CrossRef][Web of Science][Medline]
- Monte S, Macchia A, Pellegrini F, Romero M, Lepore V, D
ttore A, Saugo M, Tavazzi L, Tognoni G. (2006) Antithrombotic treatment is strongly underused despite reducing overall mortality among high-risk elderly patients hospitalized with atrial fibrillation. Eur Heart J 27:2217–2223.[Abstract/Free Full Text] - Van Es RF, Jonker JJ, Verheugt FW, Deckers JW, Grobbee DE. (2002) Aspirin and coumadin after acute coronary syndromes (the ASPECT-2 Study): a randomized controlled trial. Lancet 360:109–113.[CrossRef][Web of Science][Medline]
- Hurlen M, Abdelnoor M, Smith P, Erikssen J, Arnesen H. (2002) Warfarin, aspirin, or both after myocardial infarction. N Engl J Med 347:969–974.
[Abstract/Free Full Text] - Buresly K, Eisenberg MJ, Zhang X, Pilote L. (2005) Bleeding complications associated with combinations of aspirin, thienopyridine derivatives and warfarin in elderly patients following acute myocardial infarction. Arch Intern Med 165:784–789.
[Abstract/Free Full Text]
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