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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\n            \u003Cp id=\u0022p-1\u0022\u003EFour conditions drive the clinical conundrum regarding the use of novel oral anticoagulants in patients also receiving dual antiplatelet therapy (DAPT): atrial fibrillation, left ventricular and intracardiac thrombus, mechanical valve prosthesis, and venous thrombotic disease and pulmonary embolism. Recurrent thrombotic events in patients on DAPT also could be considered a legitimate addition to this list. This article reviews the evidence for treatment approaches.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EThrombotic Disorders\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EFour conditions drive the clinical conundrum regarding the use of novel oral anticoagulants (NOACs) in patients also receiving dual antiplatelet therapy (DAPT): atrial fibrillation (AF), left ventricular and intracardiac thrombus, mechanical valve prosthesis, and venous thrombotic disease and pulmonary embolism. Recurrent thrombotic events in patients on DAPT also could be considered a legitimate addition to this list. Paul W. Armstrong, MD, University of Alberta, Edmonton, Alberta, Canada, reviewed the evidence for treatment approaches.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EPatients with acute coronary syndromes (ACS) and AF pose a particular risk and optimal therapy is unclear. About 2% to 21% of ACS patients have AF [Connolly S et al. \u003Cem\u003ELancet\u003C\/em\u003E 2006; Leon MB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 1998]. Notably, compared with warfarin, aspirin and clopidogrel are more effective in ACS but less effective in AF.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe risk of events and bleeding is increased in patients with ACS and AF. A 5-fold increased risk of 30-day death in patients who had bleeding was found in some 34,146 patients in the OASIS registry, OASIS-2 trial, and CURE trial [Eikelboom JW et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2006]. A progressive and substantial risk of significant bleeding occurs as the number of antithrombotic (AT) and antiplatelet (AP) drugs increase; however, there was little effect on overall mortality in a Danish registry of nearly 40,812 patients, most of whom had acute myocardial infarction (MI) [Sorensen R et al. \u003Cem\u003ELancet\u003C\/em\u003E 2009]. By contrast, in another Danish registry of 11,480 patients with AF who had an MI or percutaneous coronary intervention (PCI), there was an inverse relationship between the number of thromboembolic events (cardiovascular death, MI, ischemic stroke) and the rate of fatal and nonfatal bleeding as the number of AT and AP drugs increased [Lamberts M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2012]. The PRODIGY trial explored the optimal duration of DAPT and showed little additional benefit on clinical and ischemic endpoints with 24 months compared with 6 months of DAPT [Valgimigli M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2012].\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EThe WOEST study in ACS patients showed that the primary endpoint of any bleeding was lower with warfarin plus clopidogrel compared with these drugs plus aspirin (19.4% vs 44.4%, respectively; HR, 0.36; 95% CI, 0.26 to 0.50; p\u0026lt;0.001), and the incidence of the secondary composite clinical endpoint was lower with DAPT (11.1% vs 17.6% with triple therapy; HR, 0.60; 95% CI, 0.38 to 0.94; p=0.025) [De Wilde WJ et al. \u003Cem\u003ELancet\u003C\/em\u003E 2013]. Dr. Armstrong noted that although the study was underpowered for the secondary endpoint, the findings suggest it may be possible to forego aspirin in selected patients.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EThe likelihood of noncardiac surgery after stenting is a concern given the need for interruption of antithrombotic therapy. The rate of noncardiac surgery was 27.5% at 2 years in one cohort, with the incidence of major adverse cardiac events highest within the first 6 weeks (11.6%) and decreasing over time (3.5% at 12 to 24 months) [Hawn MT et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2013]. Recommendations based on these retrospective data are to 1) postpone nonurgent surgery until 6 months after stent implant; 2) use only one AP agent for urgent surgery \u0026lt;6 months; 3) consider short-term bridging with glycoprotein IIb\/IIIa inhibitors or cangrelor if AP must be discontinued when stent thrombosis risk is highest; and 4) restart AP therapy soon after surgery once the bleeding risk returns toward the preoperative baseline [Hawn MT et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2013; Brilakis ES, Banerjee S. \u003Cem\u003EJAMA\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EDr. Armstrong said that five questions must be addressed to determine the benefit-risk ratio for each patient:\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n            \u003Cp id=\u0022p-8\u0022\u003EWhat is the risk of the underlying condition?\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n            \u003Cp id=\u0022p-9\u0022\u003EWhat is the likely pattern and time frame of risk?\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n            \u003Cp id=\u0022p-10\u0022\u003EWhat is the risk of novel incremental treatment?\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \u003Cp id=\u0022p-11\u0022\u003EWhat is the likely pattern and time frame of risk reduction?\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n            \u003Cp id=\u0022p-12\u0022\u003EWhat is the time frame for intersection of perceived treatment risk and likely benefit?\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-13\u0022\u003EThe recommendations for oral anticoagulants in ACS from the European Society of Cardiology (ESC) are shown in \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E [Steg PG et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012], and for duration of triple therapy in AF after stenting are shown in \u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E [Verheugt F W et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2013].\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\/13\/20\/39\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022ESC Recommendations for OACs in ACS\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-772203623\u0022 data-figure-caption=\u0022ESC Recommendations for OACs in ACS\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\/13\/20\/39\/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\/13\/20\/39\/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\/13\/20\/39\/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\/13372\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 attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-14\u0022 class=\u0022first-child\u0022\u003EESC Recommendations for OACs in ACS\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EASA=aspirin; AF=atrial fibrillation; DAPT=dual antiplatelet therapy; OAC=oral anticoagulant.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Steg PG et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2012;35(20):2569. With permission from Oxford University Press.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\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\/13\/20\/39\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Recommendations for Duration of Triple Therapy After Stenting in AF\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-772203623\u0022 data-figure-caption=\u0022Recommendations for Duration of Triple Therapy After Stenting in AF\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\/13\/20\/39\/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\/13\/20\/39\/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\/13\/20\/39\/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\/13374\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 attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003ERecommendations for Duration of Triple Therapy After Stenting in AF\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003EACS=acute coronary syndromes; BMS=bare-metal stent; DES=drug-eluting stent; VKA=vitamin K antagonist.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EReproduced from Verheugt FW et al. Antithrombotic Therapy During and After Percutaneous Coronary Intervention in Patients With Atrial Fibrillation. \u003Cem\u003ECirculation\u003C\/em\u003E 2013;128:2058\u20132061. With permission from Lippincott, Williams and Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-16\u0022\u003EDr. Armstrong sees on the horizon smarter dosing, \u003Cem\u003Ein vitro\u003C\/em\u003E physiologic monitoring, personalized medicine, effective antidotes, and a dynamic assessment of risk-benefit. The ongoing PIONEER AF-PCI study [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01830543\u0026amp;atom=%2Fspmdc%2F13%2F20%2F39.atom\u0022\u003ENCT01830543\u003C\/a\u003E] will help to answer the question of appropriate AT therapy in patients with ACS and AF.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\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\/13\/20\/39.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?nznk41\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?nznk41\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}