Recommendation 24. If age is < 65 years and Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) = 0, we recommend DAPT alone with ASA 81 mg daily with clopidogrel 75 mg daily for 6 months (and up to 1 year; Strong Recommendation; High-Quality Evidence).
Values and preferences. The risk of stroke varies from approximately 0.7% per year in patients younger than 65 years of age and CHADS2 score of 0, to approximately 2.1% per year in patients 65-74 years of age. The risk of stent thrombosis is greatest in the first month after PCI and declines thereafter. In patients with AF at lower risk of stroke, this recommendation gives greater weight to the prevention of future coronary events and less major bleeding with DAPT than with OAC, and less weight to the greater risk of stroke with DAPT than with OAC.
Practical tip. In patients who are at high risk of bleeding, the duration of DAPT should be shortened to a minimum of 1 month (if a BMS was used) or 3 months (if a DES was used) as per recommendation 5.
Recommendation 25. If age ≥ 65 years or CHADS2 ≥ 1, we suggest OAC plus clopidogrel 75 mg daily for at least 1 month (and up to 12 months) after BMS implantation and for at least 3 months (and up to 12 months) after DES implantation (Weak Recommendation; Moderate-Quality Evidence).
Values and preferences. The risk of stroke is increased to 2.1% per year in 65- to 74-year-old patients and even higher in patients older than 75 years, providing a rationale for the inclusion of OAC in the regimen. The suggestion for OAC and clopidogrel (and omission of ASA) is on the basis of randomized trials that showed a lower risk of bleeding with this regimen vs warfarin with clopidogrel and ASA (traditional triple therapy). Although the evidence suggests a major compromise in efficacy is unlikely by omitting ASA, it is acknowledged that none of the randomized trials were individually powered to detect moderate differences in thrombotic events. Doses of OAC evaluated in randomized trials of patients with AF who undergo PCI are shown in Table 4. Rivaroxaban 15 mg daily (10 mg daily in patients with renal dysfunction) with clopidogrel and dabigatran 110 or 150 mg BID and clopidogrel have been evaluated in randomized trials vs traditional warfarin-based triple therapy. At the time this document was written, randomized trials evaluating apixaban- and edoxaban-based regimens in patients with AF who undergo PCI were in progress, so no dose recommendations with these agents are provided.