New guidance on antithrombotic use in AF patients with ACS

by Tanya Kenny

A new European joint consensus document on the use of antithrombotic drugs, including the non-vitamin K antagonist oral anticoagulants (NOACs), in patients with atrial fibrillation (AF) presenting with an acute coronary syndrome (ACS) and undergoing PCI is published today in the European Heart Journal.

The comprehensive consensus document was written jointly by the ESC Working Group on Thrombosis, the European Heart Rhythm Association (EHRA), the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Acute Cardiovascular Care Association (ACCA), all of the ESC. It was also endorsed by two international societies, the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society.

Professor Gregory YH Lip (UK), Chairperson of the Task Force, said: "This document reflects the new evidence and various advances in thromboprophylaxis for since 2010, when the last consensus document on this topic was published (2). Since the 2010 document, NOACs have been introduced, with subsequent changes in the approach to stroke prevention for AF patients. New interventional procedures are also being used in which patients with AF may be at risk of thromboembolism."

He added: "We provide the first comprehensive recommendations on the use of NOACs in this setting, as well as more emphasis on the need for good anticoagulation control when vitamin K antagonists (VKAs) are used. The paper also reflects the diminished role of aspirin in AF stroke prevention guidelines (3), various improvements in angioplasty/stent technology, and the results of new randomised trials including WOEST. Areas for further research are also highlighted."

No published trial thus far has directly evaluated the use of NOACs in patients with ACS and AF, although ongoing trials will address this. The consensus document states that "there is no strong evidence to suggest that NOACs behave differently to VKAs in the setting of ACS or stenting." It recommends that ACS patients who develop new-onset AF while on dual antiplatelet therapy should also be started with a VKA or NOACs.

Drug-eluting stents are also recommended over bare metal stents in patients with AF. Professor Lip said: "New generation drug-eluting stents are less thrombogenic and may not require prolonged dual antiplatelet drugs (ie. aspirin plus clopidogrel) on top of (so-called 'triple therapy'). Prolonged triple therapy can substantially increase the risk of bleeding."

He added: "The most difficult decision was whether or not to have a period of initial triple therapy after stent implantation, given the findings of the WOEST trial which implied an adverse effect of triple therapy on bleeding and death. Whilst a preference for a (shortened) period of triple therapy remains in the guidance, we recommend that dual therapy with oral anticoagulation and clopidogrel may be considered as an alternative to triple therapy in selected AF patients at low risk of stent thrombosis or recurrent cardiac events."

Professor Kurt Huber (Austria), Co-Chairperson of the Task Force, said: "In the last four years, since the previous document, there have been many developments including the introduction of NOACs on the market. An update was needed to provide clinicians with guidance on how to manage these patients."

He added: "The recommendations will especially help patients with ACS who in addition need anticoagulation because they have AF and a CHA2DS2-VASc score greater than one. This group represents about 10-15% of the patients we see on a daily basis in interventional and acute cardiovascular therapy. This is a relatively large number of patients and clinicians need up-to-date advice."

Professor Stephan Windecker (Switzerland), another Co-Chairperson of the Task Force, commented: "The joint consensus document is exemplary in providing collective guidance on difficult clinical scenarios devoid of randomised clinical trials. Particularly, the issue of among patients with AF and ACS or undergoing PCI is addressed in detail with helpful recommendations for routine clinical practice including the choice of stent type."

He continued: "Moreover, TAVI assumes an increasingly recognised role in the treatment of elderly patients with severe aortic stenosis, who also suffer from AF in more than 30% of cases. The document addresses this issue for the first time and summarises available data."

Professor Lip concluded: "The document published today provides very focused, clear and comprehensive recommendations that are based on the very latest evidence on how best to manage this complex group of ."

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