Triple therapy: A review of antithrombotic treatment for patients with atrial fibrillation undergoing percutaneous coronary intervention

Novel horizons in anticoagulation: the emerging role of factor XI inhibitors across different settings

Anticoagulants have long been fundamental in preventing and treating thromboembolic disorders, with a recent shift of focus towards direct oral anticoagulants, thanks to their ease of use, efficacy, and safety. Despite these advancements, bleeding complications remain a major concern with any anticoagulant, highlighting the need for safer drugs. Factor XI (FXI) inhibitors have emerged as promising agents in this regard, offering a novel approach by targeting upstream factors in the coagulation system. Phase II trials have shown encouraging outcomes, indicating a reduced bleeding risk compared to that associated with traditional anticoagulants, particularly in the context of cardiovascular disease management when combined with antiplatelet therapy. However, the variability in findings and limited efficacy data call for a cautious interpretation pending insights from phase III trials. These trials are essential for validating the potential of FXI inhibitors to balance bleeding risk reduction and maintain anticoagulant efficacy. This review explores the pharmacology, potential indications, clinical data, and future directions of FXI inhibitors, providing a perspective on their evolving role in anticoagulant therapy. It also provides a detailed analysis of data from published clinical trials on FXI inhibitors in various indications. Preliminary data from ongoing trials are also outlined. As the field moves forward, a cautiously optimistic outlook can be expected, focusing on comprehensive data from phase III trials to define the role of FXI inhibitors in various clinical scenarios.

Comparative safety review of antithrombotic treatment options for patients with atrial fibrillation undergoing percutaneous coronary intervention

INTRODUCTION

Balancing antithrombotic therapy for atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI) remains a clinical challenge due to coexisting thrombogenic risks. This review emphasizes the delicate balance required to prevent ischemic events while minimizing bleeding complications, particularly in the context of risk assessment.

AREAS COVERED

This review spans from 2010 to October 2023, exploring the complexities of antithrombotic management for AF patients undergoing PCI. It stresses the need for personalized treatment decisions to optimize antithrombotic therapies effectively.

EXPERT OPINION

The evolving evidence supports double antithrombotic therapy (DAT) over triple antithrombotic therapy (TAT) for these patients, showcasing a more favorable safety profile without compromising efficacy. Non-vitamin K antagonist oral anticoagulant (NOAC)-based DAT strategies exhibit superiority in reducing major bleeding events while effectively preventing ischemic events. Recommendations from the 2023 European Society of Cardiology (ESC) Guidelines advocate for NOAC-based DAT post-PCI, endorsing safer antithrombotic profiles.Challenges persist for specific patient categories requiring both oral anticoagulants and antiplatelets, necessitating personalized approaches. Future advances in intravascular imaging and novel coronary stent technologies offer promising avenues to optimize outcomes and influence antithrombotic strategies in AF-PCI patients.

Factor XI inhibitors for the prevention of cardiovascular disease: A new therapeutic approach on the horizon?

Anticoagulant drugs that are currently used to prevent and/or treat thrombosis have some limitations that hinder their ability to meet specific clinical requirements. While these drugs effectively reduce the rates of thrombotic events, they simultaneously increase the risk of bleeding. Moreover, their risk-to-benefit balance is problematic in some patients, such as those with severe chronic kidney disease or those at high bleeding risk. A novel anticoagulation method, FXI inhibition has emerged as a promising alternative. It demonstrates a strong rationale for the prevention and treatment of venous thromboembolism and the potential fulfillment of unmet clinical needs in the cardiovascular field. A number of FXI inhibitors are currently undergoing clinical investigation. The objective of this review is to provide an overview of early results of research on FXI inhibitors in the cardiovascular setting, offering valuable insights into their potential role in shaping the future of anticoagulation.

Is triple antithrombotic therapy a safe option in patients with AF who receive drug-eluting stents?: a review article

BACKGROUND

Optimal antithrombotic therapy depicts a challenge to clinicians treating atrial fibrillation (AF) patients who are undergoing percutaneous coronary intervention (PCI). Theoretically, these patients would require a combination therapy of oral anticoagulant and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, known as triple antithrombotic therapy (TAT). However, TAT is known to carry a significant risk of bleeding. The purpose of the present paper is to provide a focused review of the evidence about the safety of TAT as well as to address contemporary directions regarding antithrombotic therapy following PCI in patients with AF who received a drug-eluting stent.

MAIN BODY

Novel oral anticoagulant studies consistently demonstrated a better safety profile when compared to Vitamin K antagonist (warfarin), especially in AF patients who have other indications of DAPT after PCI. Evidence from several studies showed that the use of TAT in AF patients undergoing stent implantation or PCI has no significant clinical benefit with more risk of major bleeding when compared to DAT. Therefore, the current recommendations for AF have taken into account the mounting evidence of antithrombotic treatment after PCI in AF patients, which has caused a major shift away from the TAT strategy toward DAT over time.

CONCLUSIONS

Cardiologists face challenges in determining the best antithrombotic treatment for AF patients after PCI with DES implantation. Growing data suggest that TAT is associated with considerable bleeding and worse safety, without significant effectiveness. Hence, TAT is strictly applied for individuals with significant thrombotic risk and low bleeding risk, and for a limited duration. This paper highlights the safety concerns of TAT and current trends in antithrombotic therapy after PCI in patients with AF and DES.

Clinical impact of high platelet reactivity in patients with atrial fibrillation and concomitant percutaneous coronary intervention on dual or triple antithrombotic therapy

High platelet reactivity (HPR) on clopidogrel is an established thrombotic risk factor after percutaneous coronary intervention (PCI). The introduction of more potent antiplatelet drugs has partially surpassed this issue. However, in the setting of concomitant atrial fibrillation (AF) and PCI clopidogrel is still the most adopted P2Y12 inhibitor. In the present study all consecutive patients with history of AF discharged from our cardiology ward with dual (DAT) or triple (TAT) antithrombotic therapy after a PCI from April 2018 to March 2021 were enrolled in an observational registry. For all subjects, blood serum samples were collected and tested for platelet reactivity by arachidonic acid and ADP (VerifyNow system) and genotyping of the CYP2C19*2 loss-of-function polymorphism. We recorded at 3 and 12-months follow-up: (1) major adverse cardiac and cerebrovascular events (MACCE), (2) major hemorrhagic or clinically relevant non-major bleeding and (3) all-cause mortality. A total of 147 patients were included (91, 62% on TAT). In 93.4% of patients, clopidogrel was chosen as P2Y12 inhibitor. P2Y12 dependent HPR resulted an independent predictor of MACCE both at 3 and 12 months (HR 2.93, 95% C.I. 1.03 to 7.56, p = 0.027 and HR 1.67, 95% C.I. 1.20 to 2.34, p = 0.003, respectively). At 3-months follow-up the presence of CYP2C19*2 polymorphism was independently associated with MACCE (HR 5.21, 95% C.I. 1.03 to 26.28, p = 0.045). In conclusion, in a real-world unselected population on TAT or DAT, the entity of platelet inhibition on P2Y12 inhibitor is a potent predictor of thrombotic risk, suggesting the clinical utility of this laboratory evaluation for a tailored antithrombotic therapy in this high-risk clinical scenario. The present analysis was performed in patients with AF undergoing PCI on dual or triple antithrombotic therapy. At 1 year follow-up MACCE incidence was consistent, and it was not different in different antithrombotic pattern groups. P2Y12 dependent HPR was a potent independent predictor of MACCE both at 3- and 12-months follow-up. In the first 3 months after stenting the carriage of CYP2C19*2 allele was similarly associated with MACCE. Abbreviation: DAT, dual antithrombotic therapy; HPR, high platelet reactivity; MACCE, major adverse cardiac and cerebrovascular events; PRU, P2Y12 reactive unit; TAT, triple antithrombotic therapy. Created with BioRender.com.

Impact of PARIS and CREDO-Kyoto Thrombotic and Bleeding Risk Scores on Clinical Outcomes in Patients With Acute Myocardial Infarction

BACKGROUND

The PARIS and CREDO-Kyoto risk scores were developed to identify patients at risks of thrombotic and bleeding events individually after percutaneous coronary intervention (PCI). However, these scores have not been well validated in different cohorts.

METHODS AND RESULTS

This 2-center registry enrolled 905 patients with acute myocardial infarction (MI) undergoing primary PCI. Patients were divided into 3 groups according to the PARIS and CREDO-Kyoto thrombotic and bleeding risk scores. The study endpoints included ischemic (cardiovascular death, recurrent MI, and ischemic stroke) and major bleeding events. Of 905 patients, 230 (25%) and 219 (24%) had high thrombotic and bleeding risks, respectively, with the PARIS scores, compared with 78 (9%) and 50 (6%) patients, respectively, with the CREDO-Kyoto scores. According to the 2 scores, >50% of patients with high bleeding risk had concomitant high thrombotic risk. During the mean follow-up period of 714 days, 163 (18.0%) and 95 (10.5%) patients experienced ischemic and bleeding events, respectively. Both PARIS and CREDO-Kyoto scores were significantly associated with ischemic and bleeding events after primary PCI. For ischemic events, the CREDO-Kyoto rather than PARIS thrombotic risk score had better diagnostic ability.

CONCLUSIONS

In the present Japanese cohort of acute MI patients undergoing contemporary primary PCI, the PARIS and CREDO-Kyoto thrombotic and bleeding risk scores were discriminative for predicting ischemic and bleeding events.

Demographic, Clinical, and Angiographic Characteristics of Atrial Fibrillation Patients Suffering From de novo Acute Myocardial Infarction: A Subgroup Analysis of the MINOCA-TR Study Population

BACKGROUND

Atrial fibrillation (AF) prevalence in patients with acute myocardial infarction (MI) ranges from 3% to 25%. However demographic, clinical, and angiographic characteristics of AF patients who admitted with de novo MI are unclear. The aim of this study was to investigate the prevalence of patients presenting with de novo MI with AF.

METHODS

The study was performed as a sub-study of the MINOCA-TR (Myocardial Infarction with Non-obstructive Coronary Arteries in Turkish Population) Registry, a multicenter, cross-sectional, observational, all-comer registry. MI patients without a known history of stable coronary artery disease and/or prior coronary revascularization were enrolled in the study. Patients were divided into AF and Non-AF groups according to presenting cardiac rhythm.

RESULTS

A total of 1793 patients were screened and 1626 were included in the study. The mean age was 61.5 (12.5) years. 70.7% of patients were men. The prevalence of AF was 3.1% (51 patients). AF patients were older [73.4 (9.4) vs. 61.0 (12.4) years, p<0.001] than non-AF patients. The proportion of women to men in the AF group was also higher than in the non-AF group (43.1% vs. 28.7%, p=0.027). Only 1 out of every 5 AF patients (10 patients, 19.6%) was using oral anticoagulants (OAC).

CONCLUSIONS

AF prevalence in patients presenting with de novo MI was lower than previous studies that issued on AF prevalence in MI cohorts. The majority of AF patients did not have any knowledge of their arrhythmia and were not undergoing OAC therapy at admission, emphasizing the vital role of successful diagnostic strategies, patient education, and implementations for guideline adaptation.

Update on Antithrombotic Therapy after Percutaneous Coronary Intervention

Percutaneous coronary intervention (PCI) has become a standard-of-care procedure in the setting of angina or acute coronary syndrome. Antithrombotic therapy is the cornerstone of pharmacological treatment aimed at preventing ischemic events following PCI. Dual antiplatelet therapy as the combination of aspirin and P2Y12 inhibitor has been proven to decrease stent-related thrombotic risks. However, the optimal duration of dual antiplatelet therapy, an appropriate P2Y12 inhibitor, and the choice of aspirin versus P2Y12 inhibitor as single antiplatelet therapy remain controversial. Furthermore, the combined use of oral anticoagulation in addition to antiplatelet therapy is a complex issue in clinical practice, such as in patients with atrial fibrillation. The key challenge concerning the optimal antithrombotic regimen is ensuring a balance between protection against thrombotic events and against excessive increases in bleeding risk. In this review article, we summarize the current evidence concerning antithrombotic therapy in patients with coronary artery disease undergoing PCI.

Triple, dual, and single antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention

In patients with atrial fibrillation (AF), concomitant coronary artery disease is often present, and vice versa. Although both AF and coronary artery disease need antithrombotic therapy to reduce ischemic events, optimal antithrombotic regimens for patients with AF undergoing percutaneous coronary intervention (PCI) remain unclear. Triple therapy, a combination of oral anticoagulant plus dual antiplatelet therapy with aspirin and P2Y₁₂ inhibitor, has been used for patients with AF undergoing PCI as an initial antithrombotic strategy in the recent decade. However, triple therapy is well-known to induce severe bleeding events. Recently, several clinical trials have been published and guideline recommendations have been updated. This review article summarizes current evidence concerning antithrombotic therapy in patients with AF undergoing PCI.