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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;15\\\/12\\\/18\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;15\\\/12\\\/18\u0022}],\u0022ac\u0022:{\u0022spmdc;15\\\/12\\\/18\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;15\\\/12\\\/18\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EThe safety and efficacy of oral anticoagulation with warfarin or the nonwarfarin oral anticoagulants have not been well established in settings such as cardioversion or ablation for atrial fibrillation, coronary artery disease, percutaneous coronary intervention, and stent placement. Recent meta-analyses and randomized trials provide new data to consider regarding the positioning of oral anticoagulation in these settings.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eatrial fibrillation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ewarfarin\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eoral anticoagulants\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Enon\u2013vitamin K antagonist oral anticoagulants\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ENOACs\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Evitamin K antagonist\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecoronary artery disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epercutaneous coronary intervention\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECAD\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EPCI\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology \u0026amp; cardiovascular medicine guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emyocardial infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EQuestions about the use of oral anticoagulants (OACs)\u2014particularly, the nonwarfarin non\u2013vitamin K antagonist OACs (NOACs)\u2014remain for patients with atrial fibrillation (AF) who require cardioversion, have coronary artery disease (CAD), or require percutaneous coronary intervention (PCI). Greg C. Flaker, MD, University of Missouri Health System, Columbia, Missouri, USA, discussed cardioversion in patients receiving an anticoagulant.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EOAC reduces the risk of stroke and systemic embolism (SSE) in patients who undergo cardioversion, with similar rates of SSE among patients who receive a vitamin K antagonist (VKA), a NOAC, or transesophageal echocardiograph\u2013guided cardioversion, as shown in several pivotal NOAC trials (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16708\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16708\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16708\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003ERelative Comparison of Outcomes After Cardioversion in Patients on Anticoagulation\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EAccording to Dr Flaker, these data suggest that the use of transesophageal echocardiograph to guide cardioversion does not lower the risk of cardiovascular events and that the risk of cardiovascular events is similar regardless of the type of NOAC used.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003ESome patients with AF require ablation or device implantation in addition to cardioversion. In these cases, the question is how to manage the NOACs during the periprocedural period. Saverio J. Barbera, MD, Stony Brook Medicine, Stony Brook, New York, USA, stated that one must consider the risks and benefits of either stopping or continuing anticoagulation, as well as individual patient characteristics, the type of procedure, or the procedural technique used. Stopping anticoagulation reduces the risk of pocket hematomas, hemothorax, and cardiac tamponade, but the risk of deep vein thrombosis, pulmonary embolism, and stroke is increased.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EThe Bruise Control study [Birnie DH et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E. 2013] evaluated continued warfarin use vs heparin bridging during pacemaker or defibrillator implantation and demonstrated that continued warfarin was favored over bridging among all subgroups, including age, use of antiplatelet therapy, type of device surgery, duration of procedure, and presence of mechanical valve.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EIn a substudy of the RE-LY trial, periprocedural anticoagulation resulted in similar rates of bleeding between the dabigatran and warfarin arms [Healey JS et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2012]. In another analysis, patients taking dabigatran who underwent device implantation did not experience any serious bleeding or thromboembolic events [Rowley CP et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E. 2013]. In a \u201creal world\u201d study, patients taking dabigatran or rivaroxaban who underwent cardiac rhythm device implantation experienced similar rates of bleeding and thromboembolic events [Kosiuk J et al. \u003Cem\u003EEuropace\u003C\/em\u003E. 2014].\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EFor ablation, 2 meta-analyses demonstrated that continued anticoagulation during catheter ablation decreased the risk of stroke or thromboembolism and major bleeding, with additional benefits when rivaroxaban or dabigatran was used instead of warfarin (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16709\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16709\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16709\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EPeriprocedural Anticoagulation During Ablation for Atrial Fibrillation\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-15\u0022\u003EAccording to these data, Dr Barbera stated that uninterrupted warfarin is safe and effective during the periprocedural period for device implantation or ablation. However, more prospective studies are needed to determine the safety and efficacy of NOACs in this setting.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EThe safety and efficacy of anticoagulation in patients who require PCI and dual antiplatelet therapy (DAPT) are also under investigation. Werner Jung, MD, University of Freiburg, Villingen-Schwenningen, Germany, stated that about 30% of patients with AF also have indications for DAPT because of CAD [Markowtiz SM. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2013]. Although OACs are indicated for the reduction of SSE in AF, DAPT has been demonstrated to provide better protection than OACs after stent implantation in patients without AF. This situation raises the question of whether triple therapy (TT)\u2014DAPT plus anticoagulation\u2014is beneficial.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EIn a meta-analysis of 9 trials, TT was favored for a significant reduction in all-cause mortality (OR, 0.59; 95% CI, 0.39 to 0.90; \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.01), and there was a higher incidence of ischemic stroke in the DAPT arm (OR, 0.38; 95% CI, 0.12 to 1.22; \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.11) [Zhao HJ et al. \u003Cem\u003EChest\u003C\/em\u003E. 2011]. However, risk of major bleeding was significantly increased over 6 months after implantation (OR, 2.12; 95% CI, 1.05 to 4.29; \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.04). In the WOEST study [Dewilde WJM et al. \u003Cem\u003ELancet\u003C\/em\u003E. 2013], the primary end point of any bleeding occurred in 44.4% of patients in the TT arm, compared with 19.4% in the double-therapy arm (HR for DAPT vs TT, 0.36; 95% CI, 0.26 to 0.50; \u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.0001). The secondary end point of death, myocardial infarction (MI), stroke, target vessel revascularization, and stent thrombosis was also greater in the TT arm (17.6% vs 11.1% with DAPT; HR for DAPT vs TT, 0.60; 95% CI, 0.38 to 0.94; \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.025).\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EHowever, an OAC plus 1 antiplatelet agent appears to provide benefit without an increased risk of bleeding. In an analysis of the Danish National Patient Registry, an OAC plus clopidogrel reduced the risk of MI or coronary death, ischemic stroke, bleeding, and all-cause mortality compared with TT (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Lamberts M et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2013]. Similarly, an analysis of the AFCAS Registry found that the safety and efficacy of VKA plus clopidogrel was comparable with DAPT or VKA plus DAPT [Rubbioli A et al. \u003Cem\u003EClin Cardiol\u003C\/em\u003E. 2014]. A meta-analysis of 6 randomized controlled trials found that with OAC plus clopidogrel, there was a significant reduction in bleeding (OR, 0.79; 95% CI, 0.64 to 0.98) without affecting the composite of death, MI, stroke, and stent thrombosis (OR, 0.90; 95% CI, 0.69 to 1.23) compared with TT [D\u2019Ascenzo F et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E. 2015].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/18\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Effect of OAC Plus Antiplatelet Therapy After Percutaneous Coronary InterventionTriple therapy (oral anticoagulant [OAC] plus aspirin plus clopidogrel [dotted line]) is used as a reference (hazard ratio = 1.00). Orange circles indicate OAC plus clopidogrel; yellow circles indicate OAC plus aspirin; green circles indicate aspirin plus clopidogrel. MI = myocardial infarction.Reprinted from J Am Coll Cardiol, Vol. 62, Lamberts M et al, Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients After Myocardial Infarction and Coronary Intervention, Pages No. 981-989, Copyright (2013), with permission from American College of Cardiology Foundation.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-844301869\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Effect of OAC Plus Antiplatelet Therapy After Percutaneous Coronary InterventionTriple therapy (oral anticoagulant [OAC] plus aspirin plus clopidogrel \u0026amp;lt;strong\u0026amp;gt;[dotted line]\u0026amp;lt;\/strong\u0026amp;gt;) is used as a reference (hazard ratio = 1.00). \u0026amp;lt;strong\u0026amp;gt;Orange circles\u0026amp;lt;\/strong\u0026amp;gt; indicate OAC plus clopidogrel; \u0026amp;lt;strong\u0026amp;gt;yellow circles\u0026amp;lt;\/strong\u0026amp;gt; indicate OAC plus aspirin; \u0026amp;lt;strong\u0026amp;gt;green circles\u0026amp;lt;\/strong\u0026amp;gt; indicate aspirin plus clopidogrel. MI = myocardial infarction.Reprinted from \u0026amp;lt;em\u0026amp;gt;J Am Coll Cardiol\u0026amp;lt;\/em\u0026amp;gt;, Vol. 62, Lamberts M et al, Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients After Myocardial Infarction and Coronary Intervention, Pages No. 981-989, Copyright (2013), with permission from American College of Cardiology Foundation.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/18\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/18\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/18\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16706\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-19\u0022 class=\u0022first-child\u0022\u003EEffect of OAC Plus Antiplatelet Therapy After Percutaneous Coronary Intervention\u003C\/p\u003E\u003Cp id=\u0022p-20\u0022\u003ETriple therapy (oral anticoagulant [OAC] plus aspirin plus clopidogrel \u003Cstrong\u003E[dotted line]\u003C\/strong\u003E) is used as a reference (hazard ratio = 1.00). \u003Cstrong\u003EOrange circles\u003C\/strong\u003E indicate OAC plus clopidogrel; \u003Cstrong\u003Eyellow circles\u003C\/strong\u003E indicate OAC plus aspirin; \u003Cstrong\u003Egreen circles\u003C\/strong\u003E indicate aspirin plus clopidogrel. MI = myocardial infarction.\u003C\/p\u003E\u003Cp id=\u0022p-21\u0022\u003EReprinted from \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E, Vol. 62, Lamberts M et al, Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients After Myocardial Infarction and Coronary Intervention, Pages No. 981-989, Copyright (2013), with permission from American College of Cardiology Foundation.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-22\u0022\u003EThe ISAR-TRIPLE trial [Fiedler KA et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2015] evaluated shortening the duration of antiplatelet therapy to 6 weeks after stent implantation in patients receiving OACs. There was no difference between the 6-week and 6-month groups in the primary end point, which was a composite of death, MI, definite stent thrombosis, stroke, or TIMI major bleeding at 9 months. For the secondary end point of BARC bleeding \u2265\u20052, there was no difference between the groups at 9 months (18.4% vs 21.3%; \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.41); however, a post hoc analysis from 6 weeks to 9 months showed a trend toward a difference between the groups based on the per-protocol analysis at 9 months (7.6% vs 12.2%; \u003Cem\u003EP\u003C\/em\u003E\u2005=\u2005.07).\u003C\/p\u003E\u003Cp id=\u0022p-23\u0022\u003EProf Jung stated that, based on the current data, a VKA plus clopidogrel appears to be a reasonable option to TT in selected patients who require a stent.\u003C\/p\u003E\u003Cp id=\u0022p-24\u0022\u003ERisk stratification for stroke and bleeding in patients with AF in clinical practice was discussed by Gregory Y. H. Lip, MD, University of Birmingham, Birmingham, United Kingdom. The CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score was adopted by the 2014 American Heart Association\/American College of Cardiology\/Heart Rhythm Society as a guideline for the management of patients with AF for stroke risk assessment [January CT et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2014]. The CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score was found to have greater sensitivity for identifying truly low-risk patients with AF who do not need OACs [Potpara TS et al. \u003Cem\u003ECirc Arrhythmia Electrophysiol\u003C\/em\u003E. 2012].\u003C\/p\u003E\u003Cp id=\u0022p-25\u0022\u003EIn AF, low risk is defined as no additional risk factors, which is a CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc score of 0 in men and 1 in women [Lip GY et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2015]. Even 1 additional risk factor increases the risk ischemic stroke or death; however, warfarin reduced the risk without substantially increasing risk of intracranial hemorrhage.\u003C\/p\u003E\u003Cp id=\u0022p-26\u0022\u003EHAS-BLED has been demonstrated to perform better than other bleeding risk scores [Lip GY et al. \u003Cem\u003ECirc Arrhythm Electrophysiol\u003C\/em\u003E. 2012] and the CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc or CHADS\u003Csub\u003E2\u003C\/sub\u003E scores [Apostolakis S et al. \u003Cem\u003EThromb Haemost\u003C\/em\u003E. 2013]. For everyday clinical practice, Prof Lip recommended using the CHA\u003Csub\u003E2\u003C\/sub\u003EDS\u003Csub\u003E2\u003C\/sub\u003E-VASc to identify patients who do not need OACs and the HAS-BLED score to guide therapy selection and identify reversible risk factors. He pointed out that OACs should not be withheld due to a high HAS-BLED score. The 2014 European consensus document on management of antithrombotic therapy in AF patients provides an algorithm for determining the optimal treatment of patients with AF and CAD or ACS (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Lip GY et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E. 2014].\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/18\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Algorithm for Treatment SelectionChoice 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\u0026#x2013;2). When vitamin K antagonists are used as part of triple therapy, international normalized ratio should be targeted at 2.0\u0026#x2013;2.5 and the time in the therapeutic range should be \u0026amp;gt;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.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-844301869\u0022 data-figure-caption=\u0022\u0026amp;lt;div xmlns=\u0026amp;quot;http:\/\/www.w3.org\/1999\/xhtml\u0026amp;quot;\u0026amp;gt;Algorithm for Treatment SelectionChoice 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\u0026#x2013;2). When vitamin K antagonists are used as part of triple therapy, international normalized ratio should be targeted at 2.0\u0026#x2013;2.5 and the time in the therapeutic range should be \u0026amp;amp;gt;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). \u0026amp;lt;em\u0026amp;gt;Eur Heart J\u0026amp;lt;\/em\u0026amp;gt;. 2014; 35 (45): 3155-3179. By permission of European Society of Cardiology.\u0026amp;lt;\/div\u0026amp;gt;\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/18\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/18\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/12\/18\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16707\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \u003Cp id=\u0022p-27\u0022 class=\u0022first-child\u0022\u003EAlgorithm for Treatment Selection\u003C\/p\u003E\u003Cp id=\u0022p-28\u0022\u003EChoice 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\u20132). When vitamin K antagonists are used as part of triple therapy, international normalized ratio should be targeted at 2.0\u20132.5 and the time in the therapeutic range should be \u0026gt;70%.\u003C\/p\u003E\u003Cp id=\u0022p-29\u0022\u003EACS, acute coronary syndromes; CAD, coronary artery disease; DAPT, dual antiplatelet therapy; PCI, percutaneous coronary intervention.\u003C\/p\u003E\u003Cp id=\u0022p-30\u0022\u003E*Dual therapy with oral anticoagulation and clopidogrel may be considered in selected patients.\u003C\/p\u003E\u003Cp id=\u0022p-31\u0022\u003E**Aspirin as an alternative to clopidogrel may be considered in patients on dual therapy (i.e. oral anticoagulation plus single antiplatelet).\u003C\/p\u003E\u003Cp id=\u0022p-32\u0022\u003E***Dual therapy with oral anticoagulation and an antiplatelet agent (aspirin or clopidogrel) may be considered in patients at very high risk of coronary events.\u003C\/p\u003E\u003Cp id=\u0022p-33\u0022\u003EReprinted 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). \u003Cem\u003EEur Heart J\u003C\/em\u003E. 2014; 35 (45): 3155-3179. By permission of European Society of Cardiology.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-34\u0022\u003EIn conclusion, OACs may be safe and effective during cardioversion and during the periprocedural period for device implantation and ablation. For patients who require PCI, an OAC plus 1 antiplatelet agent, such as clopidogrel, may be beneficial over TT.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/12\/18.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzljdp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzljdp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzljdp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}