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Expert consensus document “fills gap” for managing people with AF and atherosclerotic disease

The American College of Cardiology (ACC) has published, in the Journal of the American College of Cardiology, the “Expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease”. According to a press release, the aim is “fill the gap for much-needed guidance on antithrombotic therapy” in people with both atrial fibrillation (AF) and atherosclerotic disease.

The press release reports that around 1 in 4 individuals will develop AF during their lifetime, which “increases their risk of stroke fourfold to fivefold”. For most patients with AF, it adds, treatment with oral anticoagulant therapy is associated with significantly lower stroke rates compared with aspirin or placebo. Furthermore, the press release explains that people with venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, also have a high overall incidence of stroke and require oral anticoagulation.

However, choosing the optimal antithrombotic regimen for patients with atherosclerotic cardiovascular disease and concomitant AF or VTE who require an anticoagulant and antiplatelet therapy can be a challenge for clinicians. Therefore, the 2020 Expert Consensus Decision Pathway (ECDP) aims to fill the gap for much-needed guidance on antithrombotic therapy for this patient population.

This ECDP highlights that people with either AF or VTE undergoing percutaneous coronary intervention (PCI), to open a blocked artery, have usually been treated with an anticoagulant and dual antiplatelet therapy (DAPT) — so called “triple therapy”. This is because older studies showed that oral anticoagulation alone was not an optimal treatment for those undergoing PCI and, similarly, that DAPT was not an optimal treatment for AF or VTE. However, triple antithrombotic therapy significantly increases the risk of bleeding. Therefore, the writing committee of the ECDP recommends against the routine use of triple antithrombotic therapy for most patients.

Because major bleeding is associated with an up to five-fold increased risk of death following an acute coronary syndrome, the press release states, the writing committee for this document found it imperative to identify the optimal antithrombotic therapy for patients with atherosclerotic cardiovascular disease and concomitant AF or VTE requiring an anticoagulant. The goal of antithrombotic therapy for these patients is to maintain antithrombotic efficacy while mitigating bleeding. This ECDP provides guidance and recommendations for the best antithrombotic therapy regimen in this patient population.

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