ACC Issues Clinical Guidance for Antithrombotic Therapy in Patients With AF or VTE Undergoing PCI or With Atherosclerotic Cardiovascular Disease

December 18, 2020—The American College of Cardiology (ACC) announced the publication of the 2020 ACC Expert Consensus Decision Pathway (ECDP) for anticoagulant and antiplatelet therapy in patients with atrial fibrillation (AF) or venous thromboembolism (VTE) undergoing percutaneous coronary intervention (PCI) or with atherosclerotic cardiovascular disease. The document, which is a report of the ACC Solution Set Oversight Committee by Dharam J. Kumbhani, MD, et al, is available online in Journal of the American College of Cardiology.

According to ACC, choosing the optimal antithrombotic regimen for patients with atherosclerotic cardiovascular disease and concomitant AF or VTE who require an anticoagulant and antiplatelet therapy can be a challenge for clinicians. This 2020 ECDP aims to fill the gap for much-needed guidance on antithrombotic therapy for this patient population.

As noted in the ACC announcement, the ECDP highlights that patients with either AF or VTE undergoing PCI have usually been treated with the “triple therapy” of an anticoagulant and dual antiplatelet therapy (DAPT). Support for this practice came from older clinical trials that suggested an oral anticoagulant alone was not an optimal treatment for those undergoing PCI and, similarly, that DAPT was not an optimal treatment for AF or VTE. However, triple antithrombotic therapy significantly increases the risk of bleeding, and the writing committee for the document recommends against the routine use of triple antithrombotic therapy for most patients.

ACC stated that because major bleeding is associated with an up to fivefold increased risk of death after acute coronary syndrome, the writing committee for the document found it imperative to identify the optimal antithrombotic therapy for patients with atherosclerotic cardiovascular disease and concomitant AF or VTE requiring an anticoagulant. The goal of antithrombotic therapy for these patients is to maintain antithrombotic efficacy while mitigating bleeding. The ECDP provides guidance and recommendations for the best antithrombotic therapy regimen in this patient population.