title: Prevention of thromboembolism in the patient with acute coronary syndrome and atrial fibrillation: the clinical dilemma of triple therapy.
abstract: OBJECTIVE
  Atrial fibrillation in patients with acute coronary syndrome (ACS) is associated with a high thromboembolic event rate. Combined oral anticoagulant (OAC) and antiplatelet therapy (APT) are often used to reduce thromboembolic risk, recurrent coronary ischemic events, and stent thrombosis, despite the high bleeding risk. This review is timely with the recent introduction of novel OACs (NOACs), more potent antiplatelet agents, and second-generation coronary stents with a lower risk of late stent thrombosis, and considers strategies and new opportunities to reduce both thrombotic events and bleeding.
  
  
  RESULTS
  The benefits of NOACs in patients with atrial fibrillation have been shown in recent studies. New evidence indicates that single rather than dual APT may be adequate when an OAC is used in a patient with a recent coronary stent. Limited evidence suggests a NOAC is preferable to warfarin when additional APT is also required.
  
  
  CONCLUSIONS
  The implications of the new findings are to indicate strategies for more effective antithrombotic therapy, while minimizing the risk of major bleeding in patients with ACS and atrial fibrillation. However, additional research studies are required to further optimize treatment strategies in this high-risk population.
authors.affiliation: aSt Michael's Hospital bSouthlake Hospital, Newmarket cHamilton General Hospital, McMaster University, Hamilton dSunnybrook Hospital, University of Toronto eUniversity of Toronto, Toronto, Ontario, Canada.
authors.forename: David
authors.initials: D
authors.lastname: Fitchett
authors.forename: Atul
authors.initials: A
authors.lastname: Verma
authors.forename: John
authors.initials: J
authors.lastname: Eikelboom
authors.forename: Mina
authors.initials: M
authors.lastname: Madan
authors.forename: Eric
authors.initials: E
authors.lastname: Cohen
authors.forename: Alan
authors.initials: A
authors.lastname: Bell
authors.forename: Paul
authors.initials: P
authors.lastname: Dorian
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000188:drug therapy*; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D004359:Drug Therapy, Combination; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011475:Prosthesis Failure; D058921:Purinergic P2Y Receptor Antagonists / Q000627:therapeutic use*; D015607:Stents; D020521:Stroke / Q000150:complications / Q000517:prevention & control*; D013923:Thromboembolism / Q000150:complications / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists