Algorithm for Treatment Selection

Choice of antithrombotic therapy, including combination strategies of oral anticoagulation (O), aspirin (A) and/or clopidogrel (C). For Step 4, background colour and gradients reflect the intensity of antithrombotic therapy (i.e. dark background colour = high intensity; light background colour = low intensity). Solid boxes represent recommended drugs. Dashed boxes represent optional drugs depending on clinical judgement. New generation drug-eluting stent is generally preferable over bare-metal stent, particularly in patients at low bleeding risk (HAS-BLED 0–2). When vitamin K antagonists are used as part of triple therapy, international normalized ratio should be targeted at 2.0–2.5 and the time in the therapeutic range should be >70%.

ACS, acute coronary syndromes; CAD, coronary artery disease; DAPT, dual antiplatelet therapy; PCI, percutaneous coronary intervention.

*Dual therapy with oral anticoagulation and clopidogrel may be considered in selected patients.

**Aspirin as an alternative to clopidogrel may be considered in patients on dual therapy (i.e. oral anticoagulation plus single antiplatelet).

***Dual therapy with oral anticoagulation and an antiplatelet agent (aspirin or clopidogrel) may be considered in patients at very high risk of coronary events.

Reprinted from Lip GYH et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J. 2014; 35 (45): 3155-3179. By permission of European Society of Cardiology.