Abstract
The number of patients with atrial fibrillation (AF) is increasing due to the aging
of the population. In addition, the number of patients with AF and an indication for
oral anticoagulation (OAC) for the prevention of strokes increases, who are in need
for a dual antiplatelet therapy (DAPT) with acetyl salicylic acid (ASA) plus a P2Y12-Inhibitor because of an acute coronary syndrome and/or coronary stent implantation.
These patients did receive a triple therapy (TT) for 3–12 months in the past. Triple
therapy never has been studied for efficacy or safety, however, the rate of bleeding
complications in comparison to OAC or DAPT is significantly higher.
Registries and smaller trials showed that dual therapy with an OAC plus a single platelet
inhibitor may be sufficient to prevent strokes and stent thromboses/myocardial infarctions.
Four prospective randomized trials involving all four NOACs (Non-Vitamin K oral anticoagulants)
approved for stroke prevention in AF have been undertaken. The NOACs plus one antiplatelet
agent were tested versus vitamin K-antagonists plus DAPT. In the meantime, the trials
involving rivaroxaban (PIONEER AF-PCI), dabigatran (RE-DUAL PCI), apixaban (AUGUSTUS),
and edoxaban (ENTRUST-AF-PCI) have been published. The current status is that a NOAC
plus a single antiplatelet agent, mostly clopidogrel, is superior to TT with respect
to the bleeding complications, without any obvious and statistically significant disadvantage
for stroke rates or cardiac ischemic events. The international guidelines already
recommend to treat with a NOAC and one antiplatelet agent instead of TT in case the
patients bleeding risk is prevailing. Thus, TT seems not to be indicated anymore for
most patients with AF and ACS or PCI.
Demografisch bedingt steigt die Zahl der Patienten mit Vorhofflimmern und einer Indikation
für eine orale Antikoagulation zur Schlaganfallprävention, die aufgrund eines akuten
Koronarsyndroms oder einer perkutanen Koronarintervention eine duale antithrombozytäre
Therapie benötigen. Diese Patienten erhielten bislang für 3–12 Monate eine Triple-Therapie.
Doch wie ist die Studienlage dazu, welche Bedeutung haben die NOAK und was empfehlen
die Leitlinien?
Schlüsselwörter
Antikoagulation - Vorhofflimmern - PCI - akutes Koronarsyndrom - Thrombozytenhemmer
Key words
anticoagulation - atrial fibrillation - PCI - acute coronary syndrome - platelet inhibitors
