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CLINICAL STATEMENTS AND GUIDELINES

August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

>55 years in men, age >65 years in women, hyperlipidemia, hypertension, early family history of CAD, smoking). These trials involved celecoxib, rofecoxib, etoricoxib, and lumiracoxib and 3 high-dose nonsteroidal anti-inflammatory regimens: diclofenac 150 mg, ibuprofen 2400 mg, and naproxen 1000 mg daily. 11.	 A systematic review and network meta-analysis

of 4 RCTs, including 10 026 patients (39%–72% with stable CAD)23,59 showed that the combination of a DOAC with a P2Y12 inhibitor was associated with less bleeding compared with vitamin K agonists and DAPT. The omission of aspirin led to less bleeding, including intracranial bleeding, without differences in MACE, compared with strategies including aspirin.59 In an updated network meta-analysis including these trials and a fifth trial (ENTRUST-AF PCI [Edoxaban Treatment Versus Vitamin K Antagonist in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention]; N=11 542), fewer bleeding complications were observed with preserved antithrombotic efficacy when aspirin was discontinued within a few days (3–14 days) after PCI. The authors concluded that an antithrombotic regimen of vitamin K agonists plus DAPT should generally be avoided. The use of a DOAC (apixaban 5 mg twice daily or 2.5 mg twice daily in those with 2 of 3 criteria for high bleeding risk; rivaroxaban 15 mg daily; edoxaban 60 mg daily or 30 mg if creatinine clearance 15-50 mL/min, weight <60 kg, or concurrent use of specific potent P-glycoprotein inhibitors; and dabigatran 110 mg or 150 mg twice daily) plus a P2Y12 inhibitor without aspirin may be the most favorable treatment option and the preferred antithrombotic regimen for most patients with AF undergoing PCI. The AUGUSTUS trial (A Study of Apixaban in Patients with AF, not Caused by a Heart Valve Problem, who are at Risk for Thrombosis due to having had a Recent Coronary Event, such as a Heart Attack or a Procedure to Open the Vessels of the Heart) examined randomized treatment effects of lowdose aspirin (compared with placebo) and apixaban (compared with vitamin K antagonist [VKA]) on the risk of stent thrombosis and found a 2-fold increase in bleeding with aspirin while the incidence of stent thrombosis was low, occurring in <1% over 6 months. However, the study had limited power to detect a difference in stent thrombosis. Rates of stent thrombosis were lower with aspirin compared with placebo and with apixaban compared with VKA. Among patients with a high risk of stent thrombosis and an acceptable bleeding risk, the use of aspirin up to 30 days after PCI should be considered.25 12 Triple therapy after PCI in patients with AF

increases bleeding risk without significant reduction in ischemic risk.59 A recent expert consensus document recommends triple therapy with aspirin, a P2Y12 inhibitor, and an oral anticoagulant for up to 30 days after PCI for patients at particularly high risk for coronary thrombosis such as previous MI, complex lesions, presence of select traditional cardiovascular risk factors, or extensive CVD but with bleeding risk that is judged to be low.29 A subgroup analysis of the REDUAL PCI trial (Dual Therapy with Dabigatran/Ticagrelor Versus Dual Therapy with Dabigatran/Clopidogrel in ACS Patients with Indication for NOAC Undergoing PCI) examined effect of lesion complexity and clinical risk factors. This trial found that dabigatran dual therapy after PCI was associated with reduced bleeding risk compared with warfarin triple therapy, independent of the presence of procedural or clinical complexity factors. However, patients in the highest lesion complexity and clinical risk factor group had the highest hazard ratio (1.43 [95% CI, 0.74-2.77]) for death, thromboembolic event, or unplanned revascularization in the dabigatran 110 mg dual therapy compared with dabigatran 150 mg dual therapy (hazard ratio, 0.88 [95% CI, 0.33-2.36]) both compared with warfarin triple therapy.60–63

13 The AFIRE (Atrial Fibrillation and Ischemic Events

With Rivaroxaban) trial was a multicenter, openlabel trial that randomized 2236 patients with AF who had previous PCI or CABG >1 year earlier or who had CCD to rivaroxaban versus rivaroxaban plus a single antiplatelet agent (70.2% received aspirin, and 26.8% received a P2Y12 inhibitor). The primary endpoint was a composite of stroke, systemic embolism, MI, unstable angina requiring revascularization, or death from any cause, with a safety endpoint of major bleeding. Rivaroxaban monotherapy was noninferior to combination therapy for efficacy and superior for safety among patients with AF and stable CAD. In patients with stable CCD and AF, the addition of antiplatelet therapy to a VKA does not reduce the risk of recurrent coronary events or thrombosis; furthermore, this combination leads to significantly increased bleeding risk.26,64,65

14 Several studies have evaluated triple therapy with a

DOAC and DAPT as well as a DOAC and SAPT in patients with AF and recent ACS.27,28,38–44 Although these trials showed a lower risk of bleeding with a DOAC combined with a single antiplatelet agent compared with triple therapy, none of the studies were powered to clearly show differences in reducing ischemic events. Additionally, data are limited comparing either of these therapies for secondary prevention in patients with AF. This recommendation

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