Abstract
Clinicians struggle daily with the optimal regimen for patients with an indication for antiplatelet therapy after stenting and in patients needing oral anticoagulation treatment for atrial fibrillation (AF). This is not only difficult in patients with acute coronary syndrome (ACS) but also in the large number of patients with AF undergoing elective percutaneous coronary intervention (PCI). The challenge is to strike a balance between the increasing risk of bleeding events and ischemic or thrombotic events. Until recently, guidelines were based on expert consensus and a few small, many of them retrospective, trials. A so-called triple therapy with a vitamin K antagonist (VKA) and dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was recommended for patients with AF undergoing PCI in stable coronary artery disease or for those with ACS. However, severe bleeding complications remain a major issue during triple therapy, particularly in the growing aging population. In the past year, randomized controlled trials (RCT) with direct-acting oral anticoagulants (DOACs) have modified the standard use of care, now favoring dual therapy with DOACs. This review elucidates the current influential RCTs on the new antiplatelet and anticoagulation strategies for patients with AF undergoing PCI or with ACS, and discusses whether triple therapy is still required.
Zusammenfassung
In der täglichen klinischen Praxis ist das optimale Regime für Patienten mit Indikation für eine Plättchenhemmung nach Stentimplantation und für eine dauerhafte orale Antikoagulation bei Vorhofflimmern nicht nur bei Patienten mit akutem Koronarsyndrom (ACS), sondern auch bei den vielen Patienten mit Vorhofflimmern und elektiver perkutaner Koronarintervention (PCI) immer noch umstritten. Die Abwägung zwischen schweren Blutungskomplikationen und ischämischen oder thromboembolischen Ereignissen stellt weiterhin die entscheidende Herausforderung dar. Bis vor Kurzem basierten die internationalen Leitlinien maßgeblich auf Expertenempfehlungen und wenigen kleinen, zumeist retrospektiven Studien, welche einer sog. Tripeltherapie mit einem Vitamin-K-Antagonisten und einer dualen Plättchenhemmung (bestehend aus Aspirin und Clopidogrel) den Vorzug für Patienten mit Vorhofflimmern und PCI bei stabiler koronarer Herzkrankheit (KHK) oder Patienten mit ACS gaben. Unter dieser Tripeltherapie kann es gehäuft zu schwerwiegenden Blutungskomplikationen, insbesondere in der stetig wachsenden älteren Patientenpopulation. Im letzten Jahr wurden randomisierte, kontrollierte, multizentrische Studien zu den direkten oralen Antikoagulanzien (DOAC) veröffentlicht, die einer dualen Therapie mit DOAC statt einer Tripeltherapie den Vorzug gaben und zur Modifikation der aktuellen Leitlinien führten. Im vorliegenden Übersichtsartikel stellen die Autoren die für die neuen Plättchenhemmungs- und Antikoagulationstherapiestrategien relevanten aktuellen Studien für Patienten mit Vorhofflimmern und PCI oder mit akutem Koronarsyndrom dar und diskutieren, ob eine Tripeltherapie noch indiziert ist.
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N. Fluschnik, P.M. Becher, R. Schnabel, S. Blankenberg, and D. Westermann declare that they have no competing interests.
This article does not contain any studies with human participants or animals performed by any of the authors.
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Fluschnik, N., Becher, P.M., Schnabel, R. et al. Anticoagulation strategies in patients with atrial fibrillation after PCI or with ACS. Herz 43, 20–25 (2018). https://doi.org/10.1007/s00059-017-4649-z
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DOI: https://doi.org/10.1007/s00059-017-4649-z