Management of Patients with Atrial Fibrillation and Coronary Artery Disease

Anticoagulation Therapy

The American College of Cardiology recommends that DOACs are preferred over warfarin for patients with atrial fibrillation and coronary artery disease due to lower bleeding risk 1
Apixaban (Eliquis) has a more favorable GI bleeding risk profile compared to other anticoagulants, making it a suitable choice for patients with high bleeding risk 1
The standard dose of apixaban is 5 mg twice daily, but dose reduction may be necessary for patients with certain characteristics (age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 1

For patients with high bleeding risk, discontinuing aspirin while maintaining a P2Y12 inhibitor (clopidogrel) is recommended by the European Society of Cardiology 2
The European Society of Cardiology recommends continuing only one antiplatelet agent (preferably clopidogrel) in patients with recent GI bleeding on DAPT 2
Clopidogrel monotherapy is recommended as a safe and effective alternative to aspirin monotherapy in patients with coronary artery disease by the European Heart Society 3

Proton pump inhibitors are strongly recommended in patients on antithrombotic therapy with recent GI bleeding by the European Heart Society 3
Higher dose PPI (twice daily) is appropriate given the recent severe GI bleeding requiring transfusion and endoscopic intervention by the European Society of Gastroenterology 2
Gastric protection with PPIs should be maintained as long as antithrombotic therapy is administered by the European Heart Society 3

The American Gastroenterological Association recommends restarting anticoagulation a maximum of 7 days after bleeding has stopped for lower GI bleeding 4
For patients with high thrombotic risk, earlier resumption (but not before day 3) may be considered by the American Heart Association 4

No dose adjustment is required for the interaction between diltiazem and apixaban, but careful monitoring is warranted by the American Heart Association 5
Pantoprazole is preferred over omeprazole or esomeprazole when used with clopidogrel due to less effect on clopidogrel metabolism by the European Heart Society 3

Patient education regarding warning signs of bleeding, importance of medication adherence, and avoidance of NSAIDs and high alcohol consumption is crucial by the European Heart Society 3
Close follow-up within 1-2 weeks is recommended to monitor for signs of recurrent bleeding, thrombotic events, and medication adherence and side effects by the American College of Cardiology 1

Restarting anticoagulation too early (before day 3) after a significant GI bleed should be avoided by the American Heart Association 4
Using triple therapy (OAC + DAPT) which significantly increases bleeding risk without improving thrombotic outcomes should be avoided by the American College of Cardiology 1
Discontinuing both antiplatelet agents in patients with recent coronary stents should be avoided by the European Society of Cardiology 2
Failing to use PPI prophylaxis in patients on dual antithrombotic therapy with recent GI bleeding should be avoided by the European Heart Society 3