The following are key perspectives from this state-of-the-art review on management of antithrombotic therapy in atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI):

1. Most patients with AF and stroke risk factors require oral anticoagulation (OAC) to decrease their risk of stroke or systemic embolism. This is now best achieved using direct oral anticoagulants (DOACs) due to lower rates of intracranial hemorrhage as compared to vitamin K antagonists (VKAs; e.g., warfarin).
2. Approximately 5-10% of patients undergoing PCI have comorbid AF, which complicates antithrombotic therapy decisions. While guidelines recommend dual antiplatelet therapy (DAPT) for patients following PCI, this in combination with OAC therapy places patients at high risk for bleeding complications.
3. Several randomized trials have demonstrated that a regimen of a DOAC plus a single antiplatelet agent (usually clopidogrel) provides better safety than a triple therapy regimen of VKA plus DAPT.
4. For patients undergoing PCI with comorbid AF, strategies such as radial access and a brief anticoagulation washout prior to PCI may be considered to help reduce procedure-related bleeding risk. New-generation drug-eluting stents are also preferable, as they require shorter courses of antiplatelet therapy and are associated with a lower risk of stent thrombosis.
5. For patients undergoing PCI with comorbid AF, use of DOACs is preferred over VKAs. DOACs should be prescribed at stroke prevention doses (e.g., apixaban 5 mg BID) or doses specifically tested in AF plus PCI randomized trials (e.g., rivaroxaban 15 mg daily) when possible. Dose reduction with dabigatran (110 mg BID) may be considered in patients at higher bleeding risk.
6. Use of triple antithrombotic therapy (OAC plus DAPT) should be limited in duration as much as possible. In many cases, this can be limited to the peri-PCI period only. Patients at high thrombotic risk may be considered for up to 1 month.
7. When combining OAC and antiplatelet therapy, use of low-dose aspirin (81-100 mg) is preferred. Use of clopidogrel is also preferred over other P2Y12 inhibitor medications and over aspirin in most patients.
8. Most patients with AF who undergo PCI can discontinue antiplatelet therapy 12 months following stent placement. They should continue on OAC therapy long-term.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Prevention, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and ACS

Keywords: Acute Coronary Syndrome, Anticoagulants, Aspirin, Atrial Fibrillation, Drug-Eluting Stents, Embolism, Fibrinolytic Agents, Intracranial Hemorrhages, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Primary Prevention, Risk Factors, Stroke, Thrombosis, Vascular Diseases, Vitamin K, Warfarin

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