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In patients with atrial fibrillation after drug eluting stent implantation due to ACS and low bleeding risk

Acute Coronary Syndromes (ACS)

What is your antithrombotic strategy?

a. aspirin+clopisogrel+VKA 67%
b. aspirin+prasugrel or ticagrelor+VKA 8%
c. aspirin+clopidogrel+NOAC (dabigatran or rivaroxaban) 18%
d. aspirin+prasugrel or ticagrelor+NOAC 7%

What is the duration of "triple" therapy?

a. 3 Months 30%
b. 6 Months 37%
c. 12 Months 33%

Prof Gilles Montalescot (FR)

The answers to this poll make sense and the 85% of cardiologists ticking a or c are certainly correct.

-The association of a new P2Y12 antagonist with a vitamin K antagonist has not been properly tested and there is an official warning in the label of these drugs (prasugrel and ticagrelor) to avoid this association; the patients run the risk of serious bleeding and if such double or triple therapy is used the reasons for the prescription should be documented in the medical records and specific information provided to the patient.
-a similar comment can be made for the association of prasugrel or ticagrelor with a NOAC. Although there may be a rationale in particular in terms of safety, we clearly need more data before recommending such a strategy.
-aspirin+ clopidogrel + NOAC is a possibility, certainly safer than a vitamin K antagonist with aspirin and clopidogrel. Renal function needs to be checked first for eventual adjustment of the doses of these NOACs.
-one option has not been proposed which is to keep only one antiplatelet agent (clopidogrel) as tested in the WOEST trial, in combination with a vitamin K antagonist. Because this is only one trial, we need confirmation from other trials to confirm that this strategy is a valid option.
-However the results from WOEST and the recent information obtained with the last generation of DES showing a negligible stent thrombosis rate beyond 3 months, suggest that 3 months of triple therapy may be enough. If the patient is at high risk of recurrent coronary event, 6 months may be preferred. Again the cardiologists polled were correct in their votes in this second question of the Poll.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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