**2. The evaluation of embolic risk**

In patients with atrial fibrillation the main goal of antithrombotic therapy is to prevent stroke. In patients with non-valvular AF, the atherosclerotic cardiovascular disease (espe‐ cially a history of myocardial infarction) has been found to be associated with an increased incidence of stroke. Other important risks factors are diabetes, hypertension, previous stroke/ transient ischemic attack and age. In patients with non valvular AF CHADS2DS2-

© 2013 Bitigen and Oduncu; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Vasc-Score [6] derived from a European Heart Survey were found to be beneficial for esti‐ mation of the risk of stroke. This scoring system is suggested for risk stratification in both the European Society of Cardiology (ESC) [7] and the American College of Cardiology/ American Heart Association (ACC/AHA) [8] guidelines. (Table1). According to this scoring system, the patients are stratified into three risk groups as low (0), medium (1 – 2) and high (>2). While the risk of emboli is 1.3 % at score 1, the risk increases to 15.2 % at score 9. While previous embolism/TIA/stroke and age ≥75 are the major risk factors, the other clinical situa‐ tions are classified as the non-major risk factors. Not only previous myocardial infarction but also complex atheroma plaques and peripheral vascular disease have also been included in the definition of vascular disease.

tantly) in the estimation of bleeding risk [9]. HAS-BLED≥3 was found to be related to high risk of bleeding. However, parameters such as a history of stroke, old age, and hypertension also affect the risk of emboli estimated by using the CHA₂DS₂-Vasc-Score,. Thus, patients

Anticoagulant Therapy in Patients with Atrial Fibrillation and Coronary Artery Disease

**Letter Clinical characteristic\* Point** H Hypertension 1 A Abnormal renal or liver function (1 point each) 1 or 2 S Stroke 1 B Bleeding history 1 L Labile INR 1 E Elderly ("/>65 years) 1 D Drugs or alcohol comsumption (1 point each) 1 or 2

\*Hypertension' is defined as systolic blood pressure >160 mmHg. 'Abnormal kidney function' is defined as the pres‐ ence of chronic dialysis or renal transplantation or serum creatinine ≥200 mmol/L. 'Abnormal liver function' is defined as chronic hepatic disease (e.g. cirrhosis) or biochemical evidence of significant hepatic derangement (e.g. bilirubin >2 x upper limit of normal, in association with aspartate aminotransferase/alanine aminotransferase/alkaline phospha‐ tase >3 x upper limit normal, etc.). 'Bleeding' refers to previous bleeding history and/or predisposition to bleeding, e.g. bleeding diathesis, anaemia, etc. 'Labile INRs' refers to unstable/high INRs or poor time in therapeutic range (e.g., 60%). Drugs/alcohol use refers to concomitant use of drugs, such as antiplatelet agents, non-steroidal anti-inflamma‐

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‐

tory drugs, or alcohol abuse, etc. INR = international normalized ratio. Adapted from Pisters et al (9).

Max 9 poits

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with a high bleeding risk must be carefully managed.

**Table 2.** HAS-BLED bleeding score

**4. Choosing antithrombotic therapy**


†Heart failure or moderate to severe left ventricular systolic dysfunction (e.g. LV EF < 40%)

\*Prior myocardial infarction, peripheral artery disease, aortic plaque. TIA =transient ischaemic attack.
