For patients with AF, in association with NSTEACS or STEMI, the selection of antithrombotic therapy should be on the basis of their risk of stroke as follows (Fig. 4).

8. If the patient is aged < 65 years with no CHADS₂ risk factors, we recommend an APT therapy regimen without OAC, as per Part 7, Recommendations 11-19 of the Supplementary Material (adapted from the CCS 2012 APT Guidelines).
9. If the patient is aged ≥ 65 or the CHADS₂ score ≥ 1 and no PCI is undertaken, we suggest the combination of clopidogrel 75 mg daily (rather than prasugrel or ticagrelor) and OAC be given, without concomitant ASA, for 12 months, to be followed by OAC alone (Conditional Recommendation, Low-Quality Evidence).
10. If the patient is aged ≥ 65 years or the CHADS₂ score ≥ 1 and PCI is undertaken, we suggest the combination of ASA 81 mg/d and clopidogrel 75 mg/d andOAC (TT) for 3-6 months (duration depending on the perceived risks of coronary thrombosis and major bleeding). After 3-6 months we suggest the combination of clopidogrel andOAC to be continued until 12 months after ACS, to be followed by OAC alone (Conditional Recommendation, Low-Quality Evidence).

Values and preferences. The suggestion of TT for the first 3-6 months places greater weight on more reduction of coronary events (vs OAC with clopidogrel) and on more SSE prevented (vs DAPT) but less weight on the increased risk of major bleeding. The balance of stroke/ systemic embolus prevented and major bleeds caused could be judged as appropriate only for patients with a higher risk of stroke (eg, CHADS₂ score ≥ 2).

Practical tip. Some patients who are at high risk of stent thrombosis and whose risk of major bleeding is acceptable might continue the combination of OAC with clopidogrel for longer than 12 months after ACS.

Practical tip. Some patients at particularly high risk of major bleeding might have their clopidogrel discontinued earlier than 12 months and continue to receive OAC therapy only.

Practical tip. Some clinicians might prefer the combination of clopidogrel and OAC therapy beginning from the time of PCI, placing more weight on the reduced bleeding and no increase of thrombotic events compared with TT in the WOEST trial and less value on the fact that only 25% of patients in this trial had PCI for ACS. A combination of ASA with ticagrelor, ASA with prasugrel, or ASA with clopidogrel might also be used in preference to TT for some patients with a CHADS₂ score of 1 at the lower end of the stroke risk spectrum (eg, isolated hypertension), reserving TT or OAC with clopidogrel for patients at higher stroke risk.