Recommendation 27. If age < 65 years and CHADS2 = 0, we recommend DAPT alone with ASA 81 mg daily plus a P2Y12 inhibitor (ticagrelor or prasugrel recommended for patients with ACS and clopidogrel recommended for patients who undergo elective PCI) for up to 12 months (Strong Recommendation; High-Quality Evidence).
Values and preferences. Patients with AF who are younger than 65 years and CHADS2 = 0 who undergo PCI require DAPT to reduce thrombotic coronary events. OAC is not recommended in these patients with low risk of stroke.
Practical tip. The duration of treatment with DAPT in patients with ACS (or those who undergo high-risk PCI) who also have AF with a low risk of stroke should depend on a balanced assessment of the risk of coronary thrombotic events (Table 1) and bleeding (Table 2). Patients at lower risk of coronary thrombotic events and higher risk of bleeding can be considered for shorter-duration DAPT and patients at higher risk of coronary thrombotic events and lower risk of bleeding should be considered for longer duration of DAPT.
Recommendation 28. If age ≥ 65 years or CHADS2 ≥ 1∗, we recommend an initial regimen of triple therapy with ASA 81 mg daily plus clopidogrel 75 mg daily plus reduced intensity/dose OAC. ASA may be discontinued as early as the day following PCI or it can be continued for up to 6 months of treatment, depending on the risk of recurrent coronary thrombotic events versus major bleeding (Strong Recommendation, Moderate Quality Evidence). Following ASA discontinuation, we suggest that OAC plus clopidogrel 75 mg daily be continued for up to 12 months after the initial PCI (Weak Recommendation, Moderate Evidence).∗If CHADS2 = 1 and Age < 65 another option for initial treatment (especially if high-risk for ischemic events) is DAPT alone using ASA + ticagrelor or prasugrel, similar to the recommendation for the CHADS2 = 0 patient.
Values and preferences. In patients 65-74 years of age, the risk of stroke is approximately 2.1% per year and still higher beyond age 75 years, whereas the risk of coronary events is approximately 6%-10% per year after ACS (STEMI or non-STEMI), providing a rationale for the inclusion of OAC in the post-PCI antithrombotic regimen. Because the risk of bleeding is higher with triple therapy, a reduced intensity/dose of OAC is suggested when it is used in this context. The duration of triple therapy will vary depending on an individual patient's risk of ischemic (Table 1) vs bleeding events (Table 2). In patients with a low risk of thrombotic events and a high risk of bleeding, the duration of triple therapy can be short, with omission of ASA as early as the day after PCI. In patients with a very high risk of thrombotic events and low bleeding risk, ASA could be continued longer, for up to 6 months of treatment. For patients at intermediate risk of ischemic and bleeding events the duration of aspirin will be somewhere in between (for example 1 month or 3 months).
Practical tip. All patients should receive ASA 81 mg (or 160 mg if ASA-naive) on the day of the PCI procedure. Thereafter, ASA can be discontinued as early as the day after PCI.
Practical tip. Factors associated with an increased risk of ischemic and bleeding events are shown in Tables 1 and 2.
Practical tip. When combining OAC with antiplatelet therapy, consider reducing the dose of OAC (or intensity of warfarin), with possible omission of ASA the day after PCI, because of the higher risk of bleeding in this context.
OAC regimens evaluated in the context of a triple therapy regimen include (Table 4):
The OAC regimens that have been evaluated in the context of a dual pathway regimen include (Table 4):
Practical tip. Consider using a proton pump inhibitor for protection against gastrointestinal bleeding while patients are receiving a triple therapy regimen.
Practical tip. When a P2Y12 inhibitor is to be combined with OAC as part of a dual pathway or triple therapy regimen, then clopidogrel is suggested over ticagrelor or prasugrel because of its lower risk of bleeding complications and the lack of data on ticagrelor or prasugrel in combination with OAC.
Practical tip. Several risk scores have been formulated to quantitate ischemic risk (Table 3). Although none of these scores have been validated in a population of patients with AF who undergo PCI, they might still be helpful to the clinician in estimating risk.