Patients with atrial fibrillation undergoing percutaneous coronary intervention. Current concepts and concerns: part II

Atrial fibrillation (AF) and coronary artery disease (CAD) often coexist. Both conditions confer an increased risk of acute thrombotic complications. However, the pathogenesis of thrombus development in AF and CAD is different. Coagulation activation is the main pathway in AF, and platelet activation is the hallmark of coronary thrombosis. Antithrombotic prophylaxis is essential in both conditions. In patients with AF undergoing percutaneous coronary intervention (PCI), a combination of oral anticoagulation and antiplatelet therapy is required, which elevates the risk of major bleeding. This has to be balanced against the risk of stroke and stent thrombosis. In the first part of the present review, the prerequisites for antithrombotic management in AF patients undergoing PCI are discussed. We cover the epidemiology of concomitant presentation of AF and CAD as well as differences in the pathogenesis of thrombus formation in both conditions. We evaluate data regarding a variety of antithrombotic regimens including triple therapy in line with stroke and bleeding risk assessment. Overall, triple therapy is often warranted but should be for the shortest possible duration. Although much of the current guidance comes from observational data, well designed, adequately powered randomized clinical trials are emerging to further inform practice in this challenging area.