General recommendations regarding antithrombotic therapy in the context of concomitant AF and CAD (asymptomatic, stable CAD [defined by the absence of ACS for the preceding 12 months], elective PCI, NSTEACS, or STEMI) are as follows.

1. We recommend that patients who have concomitant AF and CAD receive a regimen of antithrombotic therapy that is on the basis of a balanced assessment of their risks of stroke, of a coronary event, and of hemorrhage associated with use of antithrombotic agents (Strong Recommendation, High-Quality Evidence).
2. When OAC is indicated in the presence of CAD, we suggest a NOAC in preference to warfarin for NVAF (Conditional Recommendation, Low-Quality Evidence).

Values and preferences. The suggestion for use of a NOAC rather than warfarin places relatively greater weight on the ease of use ofNOACs vs warfarin and on the data from RCTs of NOACs vs warfarin for NVAF, showing equal or greater reduction of stroke, equal or less major bleeding, less intracranial bleeding, and no net increase in CAD outcomes. It places relatively less weight on the absence of long-term data on the effect of NOACs on coronary outcomes as opposed to the data for efficacy of warfarin.

Practical tip. When CAD is present, some expert clinicians prefer a combination of a NOAC and ASA rather than a NOAC alone in preference to warfarin alone for patients perceived to be at higher risk of coronary events and low risk of major bleeding and might choose a NOAC alone as a reasonable option in those with average to lower risk of coronary events and higher risk of bleeding.

Practical tip. In general, the recommended doses of NOACs are the usual doses studied in the RCTs of NVAF. For patients who require combinations of APT and OAC agents for concomitant AF and CAD, we suggest that measures be used to reduce the risk of bleeding, including careful consideration of Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly (>65 Years), Drugs/Alcohol Concomitantly (HASBLED) risk factors and vigorous efforts to mitigate them; specific measures during invasive procedures (radial access, small-diameter sheaths, early sheath removal from the femoral site, and minimized use of acute procedural antithrombotic therapies); consideration of proton pump inhibitors; avoidance of prasugrel and ticagrelor in conjunction with OAC; the use of warfarin in the lower international normalized ratio (INR) range; consideration of the lower effective doses of NOACs; and delaying nonurgent catheterization until there is clarity about coagulation status and renal function. If the risk of restenosis is relatively low, the option of a bare metal stent (BMS) rather than a second-generation drug-eluting stent (DES) should be considered.

• The definition of NVAF was recently revisited. The use of NOACs is contraindicated in the presence of mechanical heart valves, rheumatic mitral stenosis, or moderate and severe nonrheumatic mitral stenosis.
• It is also recommended that patients who refuse warranted OAC therapy should receive the combination of ASA and clopidogrel.