Accepted Manuscript Letter to the Editor: Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients after Myocardial Infarction and Coronary Intervention Mehmet Aytürk, MD Hamza Sunman, MD Ekrem Yeter, MD PII:

S0735-1097(14)00287-3

DOI:

10.1016/j.jacc.2013.10.089

Reference:

JAC 19754

To appear in:

Journal of the American College of Cardiology

Received Date: 1 October 2013 Accepted Date: 7 October 2013

Please cite this article as: Aytürk M, Sunman H, Yeter E, Letter to the Editor: Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients after Myocardial Infarction and Coronary Intervention, Journal of the American College of Cardiology (2014), doi: 10.1016/j.jacc.2013.10.089. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Letter to the Editor: Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients after Myocardial Infarction and Coronary Intervention

Mehmet Aytürk, MD1, Hamza Sunman, MD1, Ekrem Yeter, MD1 Department of Cardiology, Ministry Of Health Dışkapı Yıldırım Beyazıt Research and

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Educational Hospital, Ankara, Turkey

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Corresponding author:

Hamza Sunman, M.D. Department of Cardiology, Ministry Of Health Dışkapı Yıldırım

mail: [email protected]

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Disclosures: None

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Beyazıt Research and Educational Hospital, 06110, Ankara, Turkey, Tel:+903125962941, e-

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ACCEPTED MANUSCRIPT We have read with much interest the article by Lamberts et al who reported Oral Anticoagulation and Antiplatelets in Atrial Fibrillation Patients after Myocardial Infarction and Coronary Intervention, concluding that Anticoagulation(OAC) and clopidogrel was equal or better on both benefit and safety outcomes compared to triple therapy(1). The study group

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was 12165 atrial fibrillation (AF) patients hospitalized with myocardial infarction (MI) and /or undergoing percutaneous coronary intervention (PCI) between 2001 and 2009. We

congratulate the authors for their work, which evaluate the effect of antithrombotic therapy in

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real-life patients in a nationwide setting regardless of race, employment, health insurance coverage, and socioeconomic status. However, there are few aspects that in our opinion need

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clarification.

Recent Consensus Documents recommend triple therapy in patients with AF presenting with MI or those undergoing PCI including oral anticoagulation (OAC) plus aspirin 100 mg per day and clopidogrel 75 mg per day in the short term, followed by longer therapy with OAC

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plus a single antiplatelet drug, and OAC only after 1 year from the index event(2). According to European Society of Cardiology Guidelines, triple therapy (OAC, aspirin, clopidogrel) should be considered in the short term (3–6 months), or longer in selected patients at low

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bleeding risk following an MI with or without PCI in patients with AF(3). There is no

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difference between the two stent types in terms of antithrombotic treatment. In case of elective PCI, antithrombotic treatment may vary. Namely, clopidogrel should be considered in combination with warfarin plus aspirin for a minimum of 1 month after implantation of a bare metal stent (BMS), but longer with a drug-eluting stent (DES). Furthermore, duration of triple therapy may change by the type of DES (at least 3 months for a sirolimus-eluting stent and at least 6 months for a paclitaxel-eluting stent). After DES implantation delayed endothelialization causes late stent thrombosis and raises safety concerns, since there are studies suggesting that DES are associated with an increased 2

ACCEPTED MANUSCRIPT rate of this event compared to BMS(4,5). For this reason, the optimal antiplatelet therapy after PCI with DES requires a long term combination of aspirin and clopidogrel. Consequently, there are no details in the manuscript on which stent types were used as PCI. If stent types were predominantly DES, the study proves that the beneficial recommendations

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provide practical guidance for clinicians in managing a complex problem of coexisting atrial

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fibrillation and myocardial infarction with PCI.

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ACCEPTED MANUSCRIPT References 1.

Lamberts M, Gislason GH, Olesen JB et al. Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention. Journal of the American College of Cardiology 2013;62:981-9. Faxon DP, Eikelboom JW, Berger PB et al. Consensus document: antithrombotic therapy in

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2.

patients with atrial fibrillation undergoing coronary stenting. A North-American perspective. Thrombosis and haemostasis 2011;106:572-84.

European Heart Rhythm A, European Association for Cardio-Thoracic S, Camm AJ et al.

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3.

Guidelines for the management of atrial fibrillation: the Task Force for the Management of

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Atrial Fibrillation of the European Society of Cardiology (ESC). European heart journal 2010;31:2369-429. 4.

Pfisterer M, Brunner-La Rocca HP, Buser PT et al. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-

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eluting versus bare-metal stents. Journal of the American College of Cardiology 2006;48:2584-91.

Camenzind E, Steg PG, Wijns W. Stent thrombosis late after implantation of first-generation

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drug-eluting stents: a cause for concern. Circulation 2007;115:1440-55; discussion 1455.

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5.

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