Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A North American Perspective-2016 Update.
The optimal antithrombotic treatment regimen for patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation is an emerging clinical problem. Currently, there is limited evidenced-based data on the optimal antithrombotic treatment regimen, including antiplatelet and anticoagulant therapies, for these high-risk patients with practice guidelines, thus, providing limited recommendations. Over the past years, expert consensus documents have provided guidance to clinicians on how to manage patients with atrial fibrillation undergoing percutaneous coronary intervention. Given the recent advancements in the field, the current document provides an updated opinion of selected North American experts from the United States and Canada on the treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention. In particular, this document provides the current views on (1) embolic/stroke risk, (2) ischemic/thrombotic cardiac risk, and (3) bleeding risk, which are pivotal for discerning the choice of antithrombotic therapy. In addition, we describe the recent advances in pharmacology, stent designs, and clinical trials relevant to the field. Ultimately, we provide expert consensus-derived recommendations, using a pragmatic approach, on the management of patients with atrial fibrillation undergoing percutaneous coronary intervention.
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.). dominick.angiolillo@jax.ufl.edu.
Dominick J
DJ
Angiolillo
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
Shaun G
SG
Goodman
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
Deepak L
DL
Bhatt
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
John W
JW
Eikelboom
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
Matthew J
MJ
Price
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
David J
DJ
Moliterno
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
Christopher P
CP
Cannon
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
Jean-Francois
JF
Tanguay
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
Christopher B
CB
Granger
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
Laura
L
Mauri
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
David R
DR
Holmes
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
C Michael
CM
Gibson
From the Division of Cardiology, University of Florida College of Medicine-Jacksonville (D.J.A.); St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre; Canadian VIGOUR Centre, University of Alberta, Edmonton (S.G.G.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., D.P.F.); Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada (J.W.E.); Division of Cardiovascular Diseases, Scripps Clinic, La Jolla CA (M.J.P.); Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.); Brigham and Women's Hospital, Harvard Clinical Research Institute, Harvard Medical School, Boston, MA (C.P.C., L.M.); Department of Medicine, Montreal Heart Institute, Université de Montréal, QC, Canada (J.-F.T.); Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Mayo Clinic, Rochester, MN (D.R.H.); and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.).
David P
DP
Faxon
D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D032921:Consensus; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D009656:North America; D018579:Patient Selection; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D016896:Treatment Outcome
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors
anticoagulant; antiplatelet therapy; atrial fibrillation; hemorrhage; stent; thrombosis