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New guidance on antithrombotic use in AF patients with ACS having PCI published today 

Topics: Atrial Fibrillation
Date: 26 Aug 2014
Barcelona, Spain – Tuesday 26 August 2014: A new European joint consensus document on the use of antithrombotic drugs, including the non-vitamin K antagonist oral anticoagulants (NOACs), in patients with atrial fibrillation (AF) presenting with an acute coronary syndrome (ACS) and undergoing PCI is published today in the European Heart Journal (1).  

The comprehensive consensus document was written jointly by the ESC Working Group on Thrombosis, the European Heart Rhythm Association (EHRA), the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Acute Cardiovascular Care Association (ACCA), all of the ESC. It was also endorsed by two international societies, the Heart Rhythm Society and the Asia Pacific Heart Rhythm Society.
Professor Gregory YH Lip (UK), Chairperson of the Task Force, said: “This document reflects the new evidence and various advances in thromboprophylaxis for atrial fibrillation since 2010, when the last consensus document on this topic was published (2). Since the 2010 document, NOACs have been introduced, with subsequent changes in the approach to stroke prevention for AF patients. New interventional procedures are also being used in which patients with AF may be at risk of thromboembolism.”
He added: “We provide the first comprehensive recommendations on the use of NOACs in this setting, as well as more emphasis on the need for good anticoagulation control when vitamin K antagonists (VKAs) are used. The paper also reflects the diminished role of aspirin in AF stroke prevention guidelines (3), various improvements in angioplasty/stent technology, and the results of new randomised trials including WOEST. Areas for further research are also highlighted.”

No published trial thus far has directly evaluated the use of NOACs in patients with ACS and AF, although ongoing trials will address this. The consensus document states that “there is no strong evidence to suggest that NOACs behave differently to VKAs in the setting of ACS or stenting.” It recommends that ACS patients who develop new-onset AF while on dual antiplatelet therapy should also be started with a VKA or NOACs.

Drug-eluting stents are also recommended over bare metal stents in patients with AF. Professor Lip said: “New generation drug-eluting stents are less thrombogenic and may not require prolonged dual antiplatelet drugs (ie. aspirin plus clopidogrel) on top of oral anticoagulation (so-called ‘triple therapy’). Prolonged triple therapy can substantially increase the risk of bleeding.”

He added: “The most difficult decision was whether or not to have a period of initial triple therapy after stent implantation, given the findings of the WOEST trial which implied an adverse effect of triple therapy on bleeding and death. Whilst a preference for a (shortened) period of triple therapy remains in the guidance, we recommend that dual therapy with oral anticoagulation and clopidogrel may be considered as an alternative to triple therapy in selected AF patients at low risk of stent thrombosis or recurrent cardiac events.”

Professor Kurt Huber (Austria), Co-Chairperson of the Task Force, said: “In the last four years, since the previous document, there have been many developments including the introduction of NOACs on the market. An update was needed to provide clinicians with guidance on how to manage these patients.”

He added: “The recommendations will especially help patients with ACS who in addition need anticoagulation because they have AF and a CHA2DS2-VASc score greater than one. This group represents about 10-15% of the patients we see on a daily basis in interventional and acute cardiovascular therapy. This is a relatively large number of patients and clinicians need up-to-date advice.”

Professor Stephan Windecker (Switzerland), another Co-Chairperson of the Task Force, commented: “The joint consensus document is exemplary in providing collective guidance on difficult clinical scenarios devoid of randomised clinical trials. Particularly, the issue of triple therapy among patients with AF and ACS or undergoing PCI is addressed in detail with helpful recommendations for routine clinical practice including the choice of stent type.”
He continued: “Moreover, TAVI assumes an increasingly recognised role in the treatment of elderly patients with severe aortic stenosis, who also suffer from AF in more than 30% of cases. The document addresses this issue for the first time and summarises available data.”
Professor Lip concluded: “The document published today provides very focused, clear and comprehensive recommendations that are based on the very latest evidence on how best to manage this complex group of patients.”

Authors: ESC Press Office
Tel: +34 670 521 210 (ESC Spokesperson Coordinator – Tanya Kenny)
Email: press@escardio.org

Notes to editor
About the European Society of Cardiology 
The European Society of Cardiology (ESC) represents more than 80 000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.

About ESC Congress 2014
ESC Congress is currently the world's largest international congress in cardiovascular medicine. ESC Congress 2014 takes place 30 August to 3 September at the Fira Gran Via congress centre in Barcelona, Spain. 

About the ESC Working Group on Thrombosis
The mission of the ESC Working Group on Thrombosis is to provide an organisational framework for clinicians and scientists involved in the areas of thrombosis and vascular research.

About the European Heart Rhythm Association
The European Heart Rhythm Association (EHRA) is a registered branch of the ESC. Its aim is to improve the quality of life of the European population by reducing the impact of cardiac arrhythmias and reduce sudden cardiac death.

About the European Association of Percutaneous Cardiovascular Interventions
The European Association of Percutaneous Cardiovascular Interventions (EAPCI) is a registered branch of the ESC. Its aim is to reduce the burden of cardiovascular disease in Europe through percutaneous cardiovascular interventions.

About the Acute Cardiovascular Care Association
The Acute Cardiovascular Care Association (ACCA) is a registered branch of the ESC. Its aim is to improve the quality of care and outcomes of patients with acute cardiovascular diseases.

About HRS
Mission: To improve the care of patients by advancing research, education and optimal health care policies and standards.
The Heart Rhythm Society (HRS) is a leading resource on cardiac pacing and electrophysiology. This specialty organization represents medical, allied health, and science professionals from more than 70 countries who specialize in cardiac rhythm disorders.

About the Asia Pacific Heart Rhythm Society
The Asia Pacific Heart Rhythm Society (APHRS) is the first and only society organized in the Asia-Pacific region to promote excellence and advancement in the diagnosis and treatment of the patients with heart rhythm disorders. Its objectives include providing opportunities for exchanging scientific, medical and technological information among its members and with members of other national/ international organizations by hosting annual APHRS scientific sessions and other related symposia.


References (1) Lip GYH, Windecker S, Huber K, Kirchhof P, Marin F, Ten Berg J, et al. Management of Antithrombotic Therapy in Atrial Fibrillation Patients Presenting With Acute Coronary Syndrome and/or Undergoing Percutaneous Coronary or Valve Interventions: A joint Consensus Document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association [EHRA], European Association of Percutaneous Cardiovascular Interventions [EAPCI] and European Association of Acute Cardiac Care [ACCA]. Endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS).  Eur Heart J 2014

(2) Lip GY, Huber K, Andreotti F, Arnesen H, Airaksinen KJ, Cuisset T, Kirchhof P and Marin F. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/ stenting. Thrombosis and haemostasis. 2010;103:13-28.(full paper available in the ESC press kit)

(3) Camm AJ, Lip GYH, de Caterina R, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. European Heart Journal. 2012;33:2719–2747. doi:10.1093/eurheartj/ehs253