The ACC has released a new Expert Consensus Decision Pathway providing guidance and recommendations on optimal antithrombotic therapy for patients with atherosclerotic cardiovascular disease (ASCVD) and concomitant atrial fibrillation (AFib) or venous thromboembolism (VTE) who require an anticoagulant. The document was published Dec. 18 in the Journal of the American College of Cardiology.

The new Pathway, led by Chair Dharam J. Kumbhani, MD, SM, FACC, and Vice Chair Christopher P. Cannon, MD, FACC, highlights the challenges with choosing optimal antithrombotic regimen for patients needing an anticoagulant and antiplatelet therapy, including the increased risk of major bleeding associated with triple antithrombotic therapy. As a result, the Pathway recommends against the routine use of triple antithrombotic therapy for most patients and "strongly recommends" a dual antithrombotic therapy consisting of an anticoagulant and a P2y12 inhibitor for patients requiring both an anticoagulant and antiplatelet therapy after recent PCI.

The document also provides several decision pathway algorithms and is divided into four sections focused on specific clinical scenarios: 1) a patient with AFib on anticoagulant therapy who now needs a PCI and antiplatelet therapy; 2) a patient on antiplatelet therapy with new-onset AFib requiring an oral anticoagulant; 3) a patient with prior VTE receiving an anticoagulant who now needs a PCI and antiplatelet therapy; and 4) a patient on antiplatelet therapy for ASCVD with a new VTE requiring an anticoagulant.

Looking ahead, the document aims to serve as a framework for decision-making among patients who require concomitant use of an anticoagulant and antiplatelet therapy. "We hope this document will aid in the management of this common yet challenging subset of patients," write Kumbhani, Cannon and colleagues.

Expert Consensus Decision Pathways are part of ACC's overarching effort to develop Solution Sets that "address key questions facing care teams and attempt to provide practical guidance to be applied at the point of care." Many of the discussions included in the current Pathway were informed by two focused Heart House Roundtables held in 2016 and 2017.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and SIHD, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Chronic Angina

Keywords: Acute Coronary Syndrome, Atrial Fibrillation, Stents, Carotid Arteries, Hemorrhage, Platelet Aggregation Inhibitors, Anticoagulants, Atherosclerosis, Carotid Artery Diseases, Cerebrovascular Disorders, Venous Thrombosis, Coronary Artery Disease, Endarterectomy, Carotid, Coronary Artery Bypass, Myocardial Infarction, Percutaneous Coronary Intervention, Perioperative Period, Peripheral Arterial Disease, Peripheral Vascular Diseases, Therapeutics, Pulmonary Embolism, Angina, Stable, Angina, Unstable, Venous Thromboembolism, Thrombosis, Thromboembolism

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