Patients undergoing percutaneous coronary intervention (PCI) with stent implantation and
requiring chronic anticoagulation for atrial fibrillation (AF) with a CHA2DS2-VASc >1 are
required to receive triple antithrombotic therapy . This triple therapy includes dual
antiplatelet therapy with clopidogrel and aspirin in combination with an oral anticoagulant
with either a vitamin K antagonist (VKA) or an oral anticoagulant (NOAC).
Recently NOAC, inhibiting the IIa (dabigatran) or Xa (rivaroxaban and apixaban) in the
coagulation cascade have demonstrated non inferiority compared to VKA to prevent
thrombo-embolic events in non-valvular AF for patients with a CHA2DS2-VASc >1 .
Interestingly, NOAC are associated with a reduced fatal bleeding rate compared to VKA.
Overall they seem to result in a lower bleeding rate compared to VKA in association with
Recently European guidelines regarding patients requiring chronic anticoagulant therapy and
undergoing coronary stent implantation have been updated. However they are based on an expert
consensus because of the scarce data available.
These guidelines advocate the combination of dual antiplatelet therapy with clopidogrel and
aspirin in combination with the lower dose of OAC or VKA with a target INR between 2 and 2.5
. The triple therapy should be prescribed for 1 to 6 months depending on the bleeding and
thrombotic risk and the clinical setting. In patients with high bleeding risk the guidelines
suggest that a sole antiplatelet agent could be used in addition to anticoagulation following
the WOEST study . In the recently published ESC guidelines on the management of atrial
fibrillation, despite the lack of new data, the expert advocate triple therapy followed by
dual antiplatelet therapy in most patients for 12 months.
The recently published PIONEER study reinforced the possibility of the use of rivaroxaban in
these patients. In this trial including ACS and not ACS patients undergoing PCI rivaroxaban
15 mg in addition to a P2Y12 ADP receptor antagonist was associated with less clinically
relevant bleeding compared to triple therapy with VKA- aspirin and clopidogrel and similar