Atrial Fibrillation and Percutaneous Coronary Intervention: Stroke, Thrombosis, and Bleeding

  • Antonio GutierrezEmail author
  • Sunil V. Rao
Cerebrovascular Disease and Stroke

Opinion statement

Currently available data suggest that patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with stenting who do not continue oral anticoagulation are at increased risk for mortality and morbidity. In this patient population, therapy directed at reducing both thromboembolism (via oral anticoagulation) and stent thrombosis (via dual antiplatelet therapy) is necessary but is associated with an increased risk for bleeding. For patients with a high risk for thromboembolism based on published AF risk scores, the use of bare metal stents is recommended to minimize the duration of triple therapy. During the time period when triple therapy is used, the International Normalized Ratio (INR) should be maintained at the lower end of therapeutic range (2.0), and lower dose aspirin should be used. Finally, as newer oral anticoagulation agents such as dabigatran and rivaroxaban become available, further research will be required to determine their safety and efficacy in patients with AF undergoing PCI with stenting.


Atrial Fibrillation Warfarin Percutaneous Coronary Intervention Acute Coronary Syndrome Clopidogrel 
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Sunil Rao is a consultant for The Medicines Company, Terumo Medical, Bristol-Myers Squibb, AstraZeneca, Sanofi-Aventis, and Daiichi Sankyo Lilly. He has received honoraria and payment for development of educational presentations from The Medicines Company, Sanofi-Aventis, and Bristol-Myers Squibb. He has had travel/accommodation expenses covered by The Medicines Company, Terumo Medical, Sanofi-Aventis, Bristol-Myers Squibb, and AstraZeneca.

Antonio Gutierrez reports no potential conflict of interest relevant to this article.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. Jama. 2001;285:2370–5.PubMedCrossRefGoogle Scholar
  2. 2.
    Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med. 1995;155:469–73.PubMedCrossRefGoogle Scholar
  3. 3.
    Heeringa J, van der Kuip DA, Hofman A, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. 2006;27:949–53.PubMedCrossRefGoogle Scholar
  4. 4.
    Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med. 1998;339:1665–71.PubMedCrossRefGoogle Scholar
  5. 5.
    Lee KW, Lip GY. Acute coronary syndromes: Virchow's triad revisited. Blood Coagul Fibrinolysis. 2003;14:605–25.PubMedCrossRefGoogle Scholar
  6. 6.
    Ganesha Babu G, Malcolm Walker J, Yellon DM, Hausenloy DJ. Peri-procedural myocardial injury during percutaneous coronary intervention: an important target for cardioprotection. Eur Heart J. 2011;32(1):23–31.CrossRefGoogle Scholar
  7. 7.
    Rao SV, Ohman EM. Anticoagulant therapy for percutaneous coronary intervention. Circ Cardiovasc Interv. 2010;3:80–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Motovska Z, Knot J, Widimsky P. REVIEW: stent thrombosis-risk assessment and prevention. Cardiovasc Ther. 2010;28:e92–e100.PubMedCrossRefGoogle Scholar
  9. 9.
    Cutlip DE, Baim DS, Ho KK, et al. Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. Circulation. 2001;103:1967–71.PubMedGoogle Scholar
  10. 10.
    Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. Jama. 2005;293:2126–30.PubMedCrossRefGoogle Scholar
  11. 11.
    Lip GY. Does atrial fibrillation confer a hypercoagulable state? Lancet. 1995;346:1313–4.PubMedCrossRefGoogle Scholar
  12. 12.
    Fukuchi M, Watanabe J, Kumagai K, et al. Increased von Willebrand factor in the endocardium as a local predisposing factor for thrombogenesis in overloaded human atrial appendage. J Am Coll Cardiol. 2001;37:1436–42.PubMedCrossRefGoogle Scholar
  13. 13.
    Nakamura Y, Nakamura K, Fukushima-Kusano K, et al. Tissue factor expression in atrial endothelia associated with nonvalvular atrial fibrillation: possible involvement in intracardiac thrombogenesis. Thromb Res. 2003;111:137–42.PubMedCrossRefGoogle Scholar
  14. 14.
    Lip GY, Lip PL, Zarifis J, et al. Fibrin D-dimer and beta-thromboglobulin as markers of thrombogenesis and platelet activation in atrial fibrillation. Effects of introducing ultra-low-dose warfarin and aspirin. Circulation. 1996;94:425–31.PubMedGoogle Scholar
  15. 15.
    Kamath S, Chin BS, Blann AD, Lip GY. A study of platelet activation in paroxysmal, persistent and permanent atrial fibrillation. Blood Coagul Fibrinolysis. 2002;13:627–36.PubMedCrossRefGoogle Scholar
  16. 16.
    Conway DS, Buggins P, Hughes E, Lip GY. Prognostic significance of raised plasma levels of interleukin-6 and C-reactive protein in atrial fibrillation. Am Heart J. 2004;148:462–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Burstein SA. Cytokines, platelet production and hemostasis. Platelets. 1997;8:93–104.PubMedGoogle Scholar
  18. 18.
    Amrani DL. Regulation of fibrinogen biosynthesis: glucocorticoid and interleukin-6 control. Blood Coagul Fibrinolysis. 1990;1:443–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Burstein SA, Peng J, Friese P, et al. Cytokine-induced alteration of platelet and hemostatic function. Stem Cells. 1996;14 Suppl 1:154–62.PubMedCrossRefGoogle Scholar
  20. 20.
    Watson T, Shantsila E, Lip GY. Mechanisms of thrombogenesis in atrial fibrillation: Virchow’s triad revisited. Lancet. 2009;373:155–66.PubMedCrossRefGoogle Scholar
  21. 21.
    Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation. 1991;84:527–39.Google Scholar
  22. 22.
    Adjusted-dose warfarin versus low-intensity. fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation: Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet. 1996;348:633–8.CrossRefGoogle Scholar
  23. 23.
    Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857–67.PubMedGoogle Scholar
  24. 24.
    Connolly S, Pogue J, Hart R, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367:1903–12.PubMedCrossRefGoogle Scholar
  25. 25.
    Connolly SJ, Pogue J, Hart RG, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360:2066–78.PubMedCrossRefGoogle Scholar
  26. 26.
    Piccini J (2009) Preventing stroke in patients with atrial fibrillation: late-breaking, clinical trial data from ESC 2009.Google Scholar
  27. 27.
    Schomig A, Neumann FJ, Kastrati A, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med. 1996;334:1084–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Bertrand ME, Legrand V, Boland J, et al. Randomized multicenter comparison of conventional anticoagulation versus antiplatelet therapy in unplanned and elective coronary stenting. The full anticoagulation versus aspirin and ticlopidine (fantastic) study. Circulation. 1998;98:1597–603.PubMedGoogle Scholar
  29. 29.
    Urban P, Macaya C, Rupprecht HJ, et al. Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS). Circulation. 1998;98:2126–32.PubMedGoogle Scholar
  30. 30.
    Bertrand ME, Rupprecht HJ, Urban P, Gershlick AH. Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting: the clopidogrel aspirin stent international cooperative study (CLASSICS). Circulation. 2000;102:624–9.PubMedGoogle Scholar
  31. 31.
    Wang TY, Robinson LA, Ou FS, et al. Discharge antithrombotic strategies among patients with acute coronary syndrome previously on warfarin anticoagulation: physician practice in the CRUSADE registry. Am Heart J. 2008;155:361–8.PubMedCrossRefGoogle Scholar
  32. 32.•
    Lopes RD, Elliott LE, White HD, et al. Antithrombotic therapy and outcomes of patients with atrial fibrillation following primary percutaneous coronary intervention: results from the APEX-AMI trial. Eur Heart J 2009;30:2019-28.PubMedCrossRefGoogle Scholar
  33. 33.
    Ruiz-Nodar JM, Marin F, Hurtado JA, et al. 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. 2008;51:818–25.PubMedCrossRefGoogle Scholar
  34. 34.
    Hansen ML, Sorensen R, Clausen MT, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010;170:1433–41.PubMedCrossRefGoogle Scholar
  35. 35.
    Manzano-Fernandez S, Pastor FJ, Marin F, et al. Increased major bleeding complications related to triple antithrombotic therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting. Chest. 2008;134:559–67.PubMedCrossRefGoogle Scholar
  36. 36.
    Paikin JS, Wright DS, Crowther MA, Mehta SR, Eikelboom JW. Triple antithrombotic therapy in patients with atrial fibrillation and coronary artery stents. Circulation. 2010;121:2067–70.PubMedCrossRefGoogle Scholar
  37. 37.
    Hughes M, Lip GY. Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review. QJM. 2007;100:599–607.PubMedCrossRefGoogle Scholar
  38. 38.
    Independent predictors of stroke in patients with atrial fibrillation: a systematic review. Neurology. 2007;69:546–54.CrossRefGoogle Scholar
  39. 39.
    Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Europace. 2010;12:1360–420.PubMedCrossRefGoogle Scholar
  40. 40.
    Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. Jama. 2001;285:2864–70.PubMedCrossRefGoogle Scholar
  41. 41.
    Go AS, Hylek EM, Chang Y, et al. Anticoagulation therapy for stroke prevention in atrial fibrillation: how well do randomized trials translate into clinical practice? Jama. 2003;290:2685–92.PubMedCrossRefGoogle Scholar
  42. 42.
    Lip GY, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation. A comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010 Dec;41(12):2731–8. Epub 2010 Oct 21. PMID 20967400.Google Scholar
  43. 43.
    Rao SV, Eikelboom JA, Granger CB, Harrington RA, Califf RM, Bassand JP. Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007;28:1193–204.PubMedCrossRefGoogle Scholar
  44. 44.
    Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114:774–82.PubMedCrossRefGoogle Scholar
  45. 45.•
    Subherwal S, Bach RG, Chen AY, et al. Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA Guidelines) Bleeding Score. Circulation 2009, 119:1873-82. This article highlights risk factors for bleeding in NSTEMI.Google Scholar
  46. 46.•
    Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A Novel User-Friendly Score (HAS-BLED) To assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest;138:1093-100. PubMedCrossRefGoogle Scholar
  47. 47.
    King 3rd SB, Smith Jr SC, Hirshfeld Jr JW, et al. 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: 2007 Writing Group to Review New Evidence and Update the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention, Writing on Behalf of the 2005 Writing Committee. Circulation. 2008;117:261–95.PubMedCrossRefGoogle Scholar
  48. 48.
    Airoldi F, Colombo A, Morici N, et al. Incidence and predictors of drug-eluting stent thrombosis during and after discontinuation of thienopyridine treatment. Circulation. 2007;116:745–54.PubMedCrossRefGoogle Scholar
  49. 49.
    Grines CL, Bonow RO, Casey Jr DE, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007;115:813–8.PubMedCrossRefGoogle Scholar
  50. 50.
    Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2008;52:1502–17.PubMedCrossRefGoogle Scholar
  51. 51.
    Wallentin L, Yusuf S, Ezekowitz MD, et al. Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial. Lancet. 2010;376:975–83.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of MedicineDuke University School of MedicineDurhamUSA
  2. 2.Duke Clinical Research InstituteDurhamUSA

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