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Prevention of thromboembolism in the patient with acute coronary syndrome and atrial fibrillation: the clinical dilemma of triple therapy

Fitchett, Davida; Verma, Atulb; Eikelboom, Johnc; Madan, Minad; Cohen, Ericd; Bell, Alane; Dorian, Paula

Current Opinion in Cardiology: January 2014 - Volume 29 - Issue 1 - p 1–9
doi: 10.1097/HCO.0000000000000024
ARRHYTHMIAS: Edited by David Birnie

Purpose of review Atrial fibrillation in patients with acute coronary syndrome (ACS) is associated with a high thromboembolic event rate. Combined oral anticoagulant (OAC) and antiplatelet therapy (APT) are often used to reduce thromboembolic risk, recurrent coronary ischemic events, and stent thrombosis, despite the high bleeding risk. This review is timely with the recent introduction of novel OACs (NOACs), more potent antiplatelet agents, and second-generation coronary stents with a lower risk of late stent thrombosis, and considers strategies and new opportunities to reduce both thrombotic events and bleeding.

Recent findings The benefits of NOACs in patients with atrial fibrillation have been shown in recent studies. New evidence indicates that single rather than dual APT may be adequate when an OAC is used in a patient with a recent coronary stent. Limited evidence suggests a NOAC is preferable to warfarin when additional APT is also required.

Summary The implications of the new findings are to indicate strategies for more effective antithrombotic therapy, while minimizing the risk of major bleeding in patients with ACS and atrial fibrillation. However, additional research studies are required to further optimize treatment strategies in this high-risk population.

aSt Michael's Hospital

bSouthlake Hospital, Newmarket

cHamilton General Hospital, McMaster University, Hamilton

dSunnybrook Hospital, University of Toronto

eUniversity of Toronto, Toronto, Ontario, Canada

Correspondence to David Fitchett, MD, FRCP, Division of Cardiology, St Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada. Tel: +1 416 864 5627; e-mail:

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins