Anticoagulation vs Anticoagulation Plus Antiplatelet in AF + Stable CAD
🔍 Anticoagulation vs Anticoagulation Plus Antiplatelet in AF + Stable CAD
Source: Journal of the American College of Cardiology (JACC), May 2025
Title: Anticoagulation and Antiplatelet Therapy for Atrial Fibrillation and Stable Coronary Disease: Meta-Analysis of RCTs
🩺 Background:
Patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) often require long-term antithrombotic therapy. The optimal strategy—oral anticoagulation (OAC) alone vs OAC + single antiplatelet therapy (SAPT)—has been debated.
📊 Study Overview:
• 4 RCTs, 4,092 patients (mean age ~74, 20% women)
• Agents used: DOACs (edoxaban, rivaroxaban), warfarin, aspirin, clopidogrel
• Follow-up: Median 12–30 months
✅ Key Findings:
🧠 Effectiveness:
• No significant difference in ischemic outcomes (MI, stroke, embolism, death) between:
• OAC monotherapy vs OAC + SAPT
🩸 Safety:
• Major bleeding significantly lower with OAC alone (3.3% vs 5.7%; HR 0.59)
• Clinically relevant bleeding also reduced (HR 0.53)
• Bleeding benefit more pronounced in men and patients with diabetes
📘 Guideline Alignment – ESC 2024 & ACC/AHA 2023:
Patients with “AF and stable CAD” (e.g. ≥1 year – post-PCI or or post ACS)should generally be treated with:
• OAC monotherapy (e.g., apixaban, rivaroxaban)
• Avoid antiplatelet therapy unless high ischemic risk.
📌 Simplified Therapy Guide for AF Patients Undergoing PCI:
🟢 Elective PCI (Stable CAD):
• Triple therapy (OAC + aspirin + clopidogrel): for 1 week post-elective PCI
• Dual therapy (OAC + clopidogrel): from week 1 to 6 months
• OAC monotherapy: from 6 months onward, if no high ischemic risk
🔴 ACS PCI (NSTEMI/STEMI):
• Triple therapy: for up to 1 month
• Dual therapy: from month 1 to 12 months
• OAC monotherapy: after 12 months, if clinically stable
✅ Aspirin should be stopped early, and clopidogrel is preferred as the antiplatelet agent
✅ DOACs are favored over warfarin for safety and convenience
✅ Long-term goal: simplify to OAC monotherapy to reduce bleeding risk
🧾 Conclusion:
In patients with AF and stable CAD, OAC monotherapy is as effective as OAC + SAPT for preventing ischemic events and significantly safer regarding bleeding. Guidelines now support simplified, tailored therapy based on patient risk and timing after PCI or ACS.
