Ruiz-Nodar JM et al. (2008) Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation: implications for bleeding risk and prognosis. J Am Coll Cardiol 51: 818–825

Patients with atrial fibrillation receive prophylactic coumarin-based anticoagulation therapy. However, if such patients undergo percutaneous coronary intervention (PCI) and/or stent implantation they additionally require antiplatelet therapy. Currently, there is no consensus as to which antithrombotic strategies provide optimum cardiovascular protection for such patients while minimizing the risk of bleeding complications. No prospective, randomized trials have considered this question, so Ruiz-Nodar and colleagues analyzed the medical registry data of 426 patients with atrial fibrillation (mean age 71.5 years; 70.9% male) who underwent PCI and stent implantation at two Spanish hospitals.

The researchers found wide variation in the antithrombotic therapy regimens used and the duration of treatment. The majority of patients received either aspirin plus clopidogrel (40.8%), or coumarin, aspirin, and clopidogrel (50.0%). During follow-up (median 595 days), the researchers observed the clinical outcomes of these antithrombotic treatment strategies, and they recorded all bleeding events, thromboembolisms, and major adverse cardiac events (such as acute myocardial infarction, target lesion revascularization, or death). Triple therapy was associated with reduced incidences of death (17.8% vs 27.8%; P = 0.002) and major adverse cardiac events (26.5% vs 38.7%; P <0.01). There was no significant increase in bleeding events associated with the coumarin-containing antithrombotic therapy.

The authors recommend triple therapy for patients with atrial fibrillation undergoing PCI with stenting who have a low risk of bleeding complications. They explain that therapies should be tailored to individual patients, with the risk of stent thrombosis and thromboembolism balanced against the risk of bleeding while receiving triple therapy.