TRIPLE THERAPY - WALKING ON A TIGHT ROPE!

Abstract

Managing patients with atrial fibrillation (AF) requiring percutaneous interventionor those on anticoagulant therapy needing an intervention is an act of greatbalancing like walking on a tight rope. The premise revolves around three basicconsiderations - the risk of embolism and stroke due to AF, the possibility ofthrombosis due to underlying coronary obstructive disease and interventionsand more importantly the hazard of bleeding in combining different therapeuticagents.

Risk of thromboembolic stroke is determined by a host of factors. CHA DS VASC score is well-validated risk score based onage, gender and comorbidities. It identifies patients at higher risk of thromboembolism who require anticoagulants to preventstroke. HASBLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile internationalnormalized ratio [INR], elderly [>65 years], drugs/alcohol concomitantly) has been recommended as a bleeding risk score forpatients with AF, with scores Ý3 considered high risk. Both scores have to be used with a grain of common sense andconsidering patient as a whole, though the HAS-BLED score has been credited to predict bleeding significantly; thediscriminating value is overall limited and similar to CHA DS VASC score.

A brief period of washout from the anticoagulant effect of OAC is preferable whenever possible in elective and non-emergentprocedures. In patients on Vit K antagonists, those being subjected to radial approach, INR should be preferably Ü2.0 and iffemoral approach is used INR has to be Ü 1.5. In patients on NOAC, irrespective of vascular access site, treatment may bewithheld for 24 hours (or 48 hours for patients with impaired renal function with dabigatran). Although in stable CAD patientsbridging with parenteral anticoagulation can be omitted yet this should be considered for patients presenting with an ACS.

To conclude, treating patients with triple therapy in the setting of AF and PCI is like walking on a tight rope. Three importantconsiderations for all decisions making are risk of thrombo-embolism and stroke, risk for thrombotic complications and risk ofbleeding. Meticulous management is recommended pre, intra and post procedure. This entails selecting patients usingappropriate criteria, employing radial approach, using latest generation DES, starting triple therapy and then changing over toSAPT earlier or later balancing thrombotic versus bleeding risks.