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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e73 CLINICAL STATEMENTS AND GUIDELINES ventricular arrhythmias and hospital stay10 but found no evidence of a difference in rates of early all-cause death, MI, cerebrovascular events, hypotension, or bradycardia.10 14.6 Antiplatelet Therapy in Patients With Atrial Fibrillation on Anticoagulation After PCI Recommendations for Antiplatelet Therapy in Patients With Atrial Fibrillation on Anticoagulation After PCI Referenced studies that support the recommendations are summarized in Online Data Supplement 48. COR LOE Recommendations 1 B-R 1. In patients with atrial fibrillation who are undergoing PCI and are taking oral anticoagulant therapy, it is recommended to discontinue aspirin treatment after 1 to 4 weeks while maintaining P2Y12 inhibitors in addition to a non–vitamin K oral anticoagulant (rivaroxaban, dabigatran, apixaban, or edoxaban) or warfarin to reduce the risk of bleeding.1-7 2a B-R 2. In patients with atrial fibrillation who are undergoing PCI, are taking oral anticoagulant therapy, and are treated with DAPT or a P2Y12 inhibitor monotherapy, it is reasonable to choose a non–vitamin K oral anticoagulant over warfarin to reduce the risk of bleeding.1,3,4 Synopsis Patients undergoing PCI frequently have or develop concomitant indications for anticoagulant therapy, including atrial fibrillation, venous thromboembolism, and prosthetic heart valves. The most robust evidence for anticoagulant management in such patients comes from trials in patients with atrial fibrillation. The 2019 focused update of the atrial fibrillation guidelines8 gave a Class 2a recommendation to a P2Y12 inhibitor with a non–vitamin K oral anticoagulant (rivaroxaban or dabigatran) or a vitamin K antagonist (warfarin) rather than triple therapy with an anticoagulant and DAPT. Since the publication of this guideline focused update, there have been 2 additional trials1,4 examining the benefits of dual anticoagulant therapy after PCI in patients with atrial fibrillation. On the basis of analyses of these trials, the recommendations for antiplatelet and anticoagulant therapy after PCI in patients with atrial fibrillation have been updated. Recommendation-Specific Supporting Text 1. Two recent trials—the AUGUSTUS (Safety and Efficacy of Apixaban Versus Vitamin K Antagonist and Aspirin Versus Aspirin Placebo in Patients With Atrial Fibrillation and ACS and/or PCI) trial1 and the ENTRUST-AF-PCI (Edoxaban–Based Versus Vitamin K Antagonist–Based Antithrombotic Regimen After Successful Coronary Stenting in Patients With Atrial Fibrillation) trial4—examined regimens of apixaban and edoxaban and supported earlier findings,6,7 reporting lower bleeding rates in patients with atrial fibrillation who were treated with a non–vitamin K oral anticoagulant and P2Y12 inhibitor than in those treated with triple therapy after PCI. Although none of the trials was powered for ischemic endpoints, pooled data from these trials1 have shown rates of death, MI, and stent thrombosis with dual therapy that are similar to those seen with triple therapy. All patients enrolled in these trials were briefly treated with triple therapy after PCI before the aspirin was discontinued. An analysis of stent thrombosis rates suggested that 80% of events occur within 30 days of PCI.3 For this reason, it is possible that prolonging aspirin therapy to 1 month after PCI may reduce the risk of stent thrombosis.3 Therefore, in patients deemed to be at high risk of stent thrombosis, aspirin could be maintained for up to 30 days. 2. The AUGUSTUS trial2 randomized patients with atrial fibrillation undergoing PCI and found that apixaban, as compared with warfarin, reduced the rate of bleeding and was associated with a lower incidence of the combined endpoint of death or hospitalization. Compared with other treatment regimens, the combination of apixaban with a P2Y12 inhibitor was associated with the lowest rates of bleeding. The ENTRUST-AF-PCI trial4 compared edoxaban and P2Y12 monotherapy with triple therapy with a vitamin K antagonist in patients with atrial fibrillation undergoing PCI. Although there were fewer bleeding events in the first 14 days in the vitamin K antagonist arm, a landmark analysis from 14 days onward demonstrated less bleeding in the dual-therapy group. 15 RECOMMENDATIONS FOR ADDRESSING PSYCHOSOCIAL FACTORS AND LIFESTYLE CHANGES AFTER REVASCULARIZATION 15.1 Cardiac Rehabilitation and Education Recommendations for Cardiac Rehabilitation and Education Referenced studies that support the recommendations are summarized in Online Data Supplement 49. COR LOE Recommendations 1 A 1. In patients who have undergone revascularization, a comprehensive cardiac rehabilitation program (home based or center based) should be prescribed either before hospital discharge or during the first outpatient visit to reduce deaths and hospital readmissions and improve quality of life.1-4 1 C-LD 2. Patients who have undergone revascularization should be educated about CVD risk factors and their modification to reduce cardiovascular events.5-7 Downloaded from http://ahajournals.org by on October 7, 2026