Antithrombotic Therapy in Patients with Atrial Fibrillation and Coronary Artery Disease

Introduction to Antithrombotic Regimens

The American College of Cardiology recommends that patients should not take Xarelto, Plavix, and aspirin together beyond a very limited initial period, as this "triple therapy" substantially increases bleeding risk without proportionate benefit 1, 2

For patients with atrial fibrillation and stable coronary disease, the American College of Cardiology recommends stopping both Plavix and aspirin immediately and continuing Xarelto alone 1, 3
For patients with atrial fibrillation and recent PCI (<12 months), the American College of Cardiology recommends stopping aspirin immediately, continuing Plavix, and starting Xarelto, with dual therapy (Xarelto + Plavix) continuing until 6-12 months post-PCI 1, 3
For patients with atrial fibrillation and recent ACS (<12 months), the American College of Cardiology recommends stopping aspirin immediately, continuing Plavix, and starting Xarelto 1, 3

The American Heart Association recommends that brief triple therapy may be justified immediately post-PCI in high-risk patients with atrial fibrillation, with a maximum duration of 1 month (or even shorter if high bleeding risk) 2, 6

The American College of Cardiology states that triple therapy increases bleeding risk by 40-50% compared to dual or monotherapy 2
The American College of Cardiology recommends using proton pump inhibitors for gastrointestinal protection, optimizing blood pressure control, avoiding NSAIDs and other medications that increase bleeding risk, and monitoring renal function and adjusting DOAC dosing accordingly 5, 6

The American College of Cardiology prefers clopidogrel over prasugrel or ticagrelor due to lower bleeding risk, and prefers DOACs (like Xarelto) over warfarin due to lower intracranial hemorrhage risk 1, 2, 7

The American College of Cardiology recommends not continuing triple therapy beyond the acute post-PCI period, as this is the most common error leading to preventable major bleeding 2, 6
The American College of Cardiology recommends not adding antiplatelet therapy to anticoagulation for stroke prevention alone, as anticoagulation is superior and antiplatelet therapy adds only bleeding risk 2, 7