PracticeUpdate Cardiology June 2019

ACC 2019 19

Anticoagulation for AFib After Percutaneous Coronary Intervention Interview with Deepak L. Bhatt MD, MPH, FACC, FAHA, FSCAI, FESC by Aman Shah MD

sufficient evidence for me. But I think now we have, really, a large bolus of information and a trial that’s designed with a factorial design that says pretty clearly you should omit aspirin from this regimen. You can use whatever anticoagulant you want, warfarin with carefully regulated therapeutic INR, a NOAC, which would be my preference. And I’d say the data separate from here has already shown that NOACs are supe- rior to warfarin as long as there’s careful renal dosing and so forth. And here, apix- aban beat warfarin as well. So I think that the mass of data now clearly says don’t use triple therapy, use double therapy. And in general, that will be a NOAC plus an ADP receptor antagonist, most often clopidogrel. Dr. Shah: Wonderful. It’s always great when you get a clear, evidence-based recommen- dation with very little ambiguity. Dr. Bhatt: Yes, in this case that’s what happened.

apixaban had less bleeding than warfarin, but it also showed that placebo had less bleeding than aspirin. Of course, that was going to be the case, but, importantly, there was no detectable loss of efficacy with those strategies. So, in this trial, it seemed like the winning cocktail then was appropriate dose anticoagula- tion with apixaban plus a P2Y 12 inhibitor, largely it was clopidogrel. And I think one can extrapolate from this and from other tri- als and say that a strategy of a NOAC plus a second antiplatelet agent, an ADP receptor antagonist, most often clopidogrel, seems to be the way to go as opposed to full-dose anticoagulation with warfarin or a NOAC, but in particular, warfarin plus clopidogrel plus aspirin, that type of triple therapy, I hope now is finally out. Dr. Shah: That does make sense. And would that be your approach in your practice to anti- coagulation in PCI patients? Dr. Bhatt: It’s been my approach for a while, really. I felt that the WOEST trial, followed by PIONEER, followed by RE-DUAL provided

Dr. Shah: There’s an interesting trial, the AUGUSTUS trial, that talks about anticoagu- lation for A-Fib in patients who just had a PCI (percutaneous coronary intervention). Could you tell us a little bit more about this trial? Dr. Bhatt: Sure. This is a several-thousand- patient trial, very well done, randomized, and there are two important parts, the so-called factorial design. One is a randomization of apixaban, a factor Xa inhibitor, sometimes referred to as a NOAC or novel oral anticoagulant, versus warfarin, plain old warfarin. And there’s a second part of randomization, the aspirin or no aspirin. So, in these atrial fibrillation patients undergoing PCI or with an ACS (acute coronary syndrome), whether there’s typically an indication for DAPT, dual antiplatelet therapy, because of the ACS with a stent and an indication for anticoagulation because of the atrial fibrillation, what do you do? And in clinical practice, what many doctors do is so-called triple therapy, full-dose anticoagulation with DAPT. There are a number of studies, randomized studies that already show that’s a bad strat- egy, that isn’t a good strategy in trials like RE-DUAL and trials like PIONEER, older tri- als like WOEST as well. And meta-analyses of these trials have shown pretty consist- ently no loss of efficacy for using double versus triple therapy, but a lot less bleeding with double versus triple therapy as com- mon sense would suggest – three agents, of course, you’re going to bleed more than two. But still, many doctors worry that well, what about a high ischemic risk patient, someone with a left main stent, for exam- ple, or a high CHA 2 DS 2 -VASc score, can we really get away with a less intense reg- imen? So, AUGUSTUS, I believe, provides a definitive answer where it showed that therapy. And in general, that will be a NOAC plus an ADP receptor antagonist, most often clopidogrel. " " I think that the mass of data now clearly says don’t use triple therapy, use double

Go to www.practiceupdate.com/c/81079 to watch this interview with Dr. Bhatt.

© ACC/Todd Buchanan 2019

VOL. 4 • NO. 2 • 2019