General recommendations regarding antithrombotic therapy in the context of concomitant AF and CAD (asymptomatic, stable CAD, elective PCI, NSTEACS or STEMI):

Recommendation 1 - Antithrombotic therapy based on a balanced assessment of a patient’s risk of stroke (2018, updated from 2016)
We recommend that patients who have concomitant AF and coronary/arterial vascular disease (peripheral vascular disease or aortic plaque), receive an antithrombotic therapy regimen that is based on a balanced assessment of their risk of AF-related stroke, ischemic coronary event, and clinically relevant bleeding associated with the use of antithrombotic agents (Strong Recommendation, High Quality Evidence).

Practical tip (2018)
For patients requiring combinations of antiplatelet and OAC agents for concomitant AF and Coronary/arterial vascular disease, we suggest that measures be employed to reduce the risk of bleeding, including: careful consideration of modifiable bleeding risk factors with vigorous efforts to mitigate them; consideration of proton pump inhibitor use; avoidance of prasugrel and ticagrelor in conjunction with OAC; the use of warfarin in the lower target INR (e.g. 2.0-2.5); consideration of the lower effective doses of NOACs in selected patients (See Figure S8); specific measures during coronary invasive procedures (radial access, small-diameter sheaths, early sheath removal from femoral site, and minimized use of acute procedural anti-thrombotic therapies); delaying non-urgent procedures until dual pathway therapy is no longer required; use of walking aids for those with gait or balance disorders; avoidance of NSAIDs or other drugs that may increase bleeding risk; and, strict blood pressure control.

Recommendation 2 - Most patients with an indication for OAC in the presence of CAD should receive a NOAC (2018, updated from 2016)
When OAC is indicated in the presence of Coronary or arterial vascular disease, we suggest a NOAC in preference to warfarin (Weak Recommendation, Moderate-Quality Evidence).

Values and preferences (2018, updated from 2014, 2016)
The suggestion for use of a NOAC rather than warfarin places relatively greater weight on the ease of use of NOACs versus warfarin, as well as the data from RCTs of NOACs versus warfarin for NVAF (e.g. equal or greater reduction of stroke, equal or greater reduction in all-cause mortality, equal or less major bleeding, less intracranial bleeding and no net increase in CAD outcomes).

Recommendation 3 - Stable vascular disease and AF in patients at low risk of stroke/systemic thromboembolism (2018)
For patients with non-valvular AF/AFL aged < 65 years with no CHADS2 risk factors, we suggest no antithrombotic therapy for stroke prevention (Weak Recommendation, Moderate Quality Evidence), with management of their coronary or arterial vascular disease as directed by the 2018 CCS/CAIC Focused Update of the Guidelines for the Use of Antiplatelet Therapy.

Practical tip (2018)
For patients with non-valvular AF/AFL aged < 65 years with no CHADS-65 risk factors, the risk of stroke associated with AF is not sufficiently elevated to justify OAC therapy. For this group treatment should be directed at the underlying coronary/arterial vascular disease (peripheral vascular disease or aortic plaque) as outlined in the 2018 CCS/CAIC Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Therapeutic options include ASA 81 mg daily alone; or in combination with either clopidogrel 75 mg daily, ticagrelor 60 mg bid, or rivaroxaban 2.5 mg bid (when approved).

Recommendation 4 - Stable vascular disease and AF in patients at high risk of stroke/systemic thromboembolism (2018)
For patients with AF aged ≥ 65 years or with a CHADS2 score ≥ 1 and coronary or arterial vascular disease (peripheral vascular disease or aortic plaque), we recommend long-term therapy with OAC alone (Strong Recommendation, High Quality Evidence).

Practical tip (2018)
For patients with high-risk clinical or angiographic features for ischemic coronary outcomes who are at low risk of bleeding, some clinicians prefer a combination of an OAC and single antiplatelet therapy (either aspirin or clopidogrel) in preference to OAC alone.

Values and preferences (2018)
For patients with AF and stable coronary or arterial vascular disease, the CCS AF Guidelines committee felt that routine use of combination therapy (OAC plus single antiplatelet) was not justified owing to the increased risk of bleeding without a significant reduction in ischemic coronary and cerebrovascular thrombotic events.

Recommendation 5 - AF patients at higher risk of stroke undergoing PCI without high-risk features (2018, updated from 2016)
For patients with AF aged ≥ 65 years or with a CHADS2 score ≥ 1, we suggest Dual Pathway Therapy (OAC plus clopidogrel 75 mg daily) for at least 1 month after BMS implantation and at least 3 months after DES implantation (Weak Recommendation, Moderate Quality Evidence).

Practical tip (2018, updated from 2014, 2016)
For some patients < 65 years of age with CHADS2 = 1 at the lower end of the stroke risk spectrum (e.g. isolated hypertension), some clinicians prefer dual antiplatelet therapy (e.g. aspirin and ticagrelor or prasugrel) in preference to Dual Pathway Therapy (OAC plus clopidogrel).

Recommendation 6 - AF patients at higher risk of stroke undergoing PCI for ACS or elective PCI with high-risk features (2018, adapted from 2016 and from CCS 2018 Antiplatelet Therapy Guidelines)
For patients with AF aged ≥ 65 years or with a CHADS2 score ≥ 1, we recommend an initial regimen of triple antithrobotic therapy (ASA 81 mg daily plus clopidogrel 75 mg daily plus OAC) up to 6 months following PCI (Strong Recommendation, Moderate Quality Evidence). Following ASA discontinuation, which may occur as early as the day following PCI, we suggest that Dual Pathway Therapy (OAC plus clopidogrel 75 mg daily) be continued for up to 12 months after PCI (Weak Recommendation, Moderate Quality Evidence).

Practical tip (2018)
For some patients < 65 years of age with CHADS2 = 1 at the lower end of the stroke risk spectrum (e.g. isolated hypertension), some clinicians prefer dual antiplatelet therapy (e.g. aspirin and ticagrelor or prasugrel) in preference to triple therapy (OAC plus dual antiplatelet).

Practical tip (2018)
A PCI is considered high-risk for ischemic coronary outcomes based on the clinical presentation (e.g. ACS), patient characteristics (co-morbid diabetes mellitus treated with oral hypoglycemics or insulin, chronic kidney disease [eGFR < 60 mL/min], current tobacco use, prior ACS, or prior stent thrombosis), as well as PCI-related factors (multivessel PCI, multiple [≥ 3] stents implanted, total stent length > 60 mm, complex bifurcation lesion, chronic total occlusion intervention, and stent type [e.g. bioabsorbable vascular scaffold]).

Practical tip (2018)
All patients should receive ASA 81 mg (or a minimum of 160 mg if ASA naïve) on the day of the PCI procedure. ASA may be continued as part of triple antithrombotic therapy for up to 6 months for patients with a high risk of thrombotic coronary events and low risk of bleeding. ASA can be discontinued as early as the day after PCI for patients with a low risk of thrombotic coronary events and a high risk of bleeding. For patients at intermediate risk of thrombotic coronary events and intermediate risk of bleeding ASA can be continued as part of triple antithrombotic therapy for 1 month to 3 months.

Recommendation 7 - AF patients at higher risk of stroke in association with medically managed type I myocardial infarction (2018)
For patients with AF aged ≥ 65 years or with a CHADS2 score ≥ 1, we suggest that Dual Pathway Therapy (OAC plus clopidogrel 75 mg daily, rather than prasugrel or ticagrelor) be given without concomitant ASA for 12 months post ACS (Weak Recommendation, Low Quality Evidence).

Values and preferences (2018)
For patients with AF and type I MI not undergoing revascularisation, the CCS AF Guidelines committee places relatively greater emphasis on the reduction in ischemic coronary and cerebrovascular thrombotic events, rather than the increase in bleeding observed with combination therapy. When combination therapy is used the preference for clopidogrel rather than ASA is based on the findings from the CAPRIE study, where clopidogrel was demonstrated to be superior to ASA (0.5% absolute reduction in composite of vascular death, MI, or ischemic stroke; P = 0.043), well as the substantial efficacy and safety data for combination therapy utilizing clopidogrel and OAC (clopidogrel used in 88% of patients in RE-DUAL and 95% in PIONEER AF-PCI).