**4. Choosing antithrombotic therapy**

In coronary artery disease, DAPT has been found superior to aspirin plus oral anticoagulant (OAC) therapy in preventing recurrent ischemic events [10]. Although, in a long term peri‐ od, OAC therapy has been found superior to DAPT in AF patients, this therapy, especially in situations when it must be combined with DAPT, has a major bleeding incidence of up to 4.7 %. This bleeding usually happens within the first month and has been fatal in almost half of the patients [11]. Therefore, the management of patients with nonvalvular AF who re‐ quire PCI (percutaneous coronary intervention) is very important for many clinicians.

Nowadays, therapy guidelines include a therapy of low aspirin dose or no therapy for low risk patients, OAC or aspirin for medium risk patients, and a therapy of OAC in patients with a high risk. In medium risk patients, DAPT has been found inequivalent to VKA in studies conducted on DAPT therapy (aspirin+ clopidogrel). VKA is related to lower bleed‐ ing and stroke. Therefore, in medium and high thromboli risk patients, if the risk of hemor‐ rhage is high, because of the high incidence of intracranial and extra cranial bleeding incidence, the option of DAPT should not be preferred.

As a therapy regime, OAC (INR=2 – 2.5), aspirin daily ≤100 mg and clopidogrel 75 mg daily is included. In patients with a high risk of bleeding, it has been stressed in both guidelines that DES should be avoided and if possible BMS should be implanted. Among patients hav‐ ing a low and medium bleeding risk, for those who have been implanted BMS, 1 month of triple anti platelet therapy is advised. Among those patients who are DES implanted, for the limus group, 3 months of triple antiplatelet therapy is advised while for the paclitaxel group, 6 months of DAPT is advised. Furthermore, in DES implanted patients, a dual thera‐ py of OAC plus aspirin up to 1 year or OAC plus clopidogrel is advised and after 1 year only OAC mono therapy is advised. Therefore, DES implantation should be avoided be‐

Anticoagulant Therapy in Patients with Atrial Fibrillation and Coronary Artery Disease

http://dx.doi.org/10.5772/54147

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Elective BMS 1 month: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100

Elective DES 3 (-olimus group) to 6 (paclitaxel) months: triple therapy of warfarin

ACS DES/BMS 6 months: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/

Elective BMS 2–4 weeks: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100

ACS BMS 4 weeks: triple therapy of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/

ACS=Acute coronary syndrome, BMS=Bare metal stent, DES=Drug eluted stent, INR=International normalized ratio

**Table 3.** ESC suggestions for anticoagulation in patients with coronary stent who have medium and high emboli risk

\*Combination of warfarin (INR 2.0–2.5) + aspirin ≤ 100 mg/day may be considered as an alternative.

Drug-eluting stents should be avoided.Adapted from Lip et al

mg/day + clopidogrel 75 mg/day Lifelong: warfarin (INR 2.0–3.0) alone

(INR 2.0–2.5) + aspirin ≤ 100 mg/day + clopidogrel 75 mg/day Up to 12 months: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/day (or aspirin 100 mg/day)\* Lifelong: warfarin (INR 2.0–3.0) alone

day + clopidogrel 75 mg/day Up to 12 months: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/day (or aspirin 100 mg/day)\* Lifelong: warfarin (INR 2.0–3.0) alone

> mg/day + clopidogrel 75 mg/day Lifelong: warfarin (INR 2.0–3.0) alone

day + clopidogrel 75 mg/day Up to 12 months: combination of warfarin (INR 2.0–2.5) + clopidogrel 75 mg/day (or aspirin 100 mg/day); mg/day)\* Lifelong: warfarin (INR 2.0–3.0) alone

cause it requires long term dual and triple therapy (Table3).

Low-Medium HAS-BLED (0 – 2)

High HAS-BLED (≥3)

**Hemorrhagic risk Clinic Stent type Anticoagulation regime**

In the abovementioned patients the low dose dabigatran option must be considered and if they are treated with VKA, a lower INR (1.8-2.5) target should be chosen. However accord‐ ing to the studies made, patients with an INR <2 have double the risk of stroke compared to patients whose INR is > 2.
