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Across the board in patients with ACS and underlying CAD who also have AFib and are treat with a bare-metal stent, then physicians has some leeway in choosing the best treatment regimen. Most of our patients, however, are candidates for drug-eluting stents, and as a result the clinical decision making becomes a much more difficult process.
With a bare-metal stent it is possible to use low-dose aspirin and stop the other antiplatelet agent (clopidogrel, prasugrel, or ticagrelor) at 1 month, while keeping the warfarin target INR at a slightly lower, 2 to 2.5 range. This represents one strategy for treating this subset of “triple therapy” patients with AFib – provided they are treated with bare-metal stents.
A more controversial challenge arises in the management of patients with AFib and CAD and/or ACS, but who do not receive a stent for whatever reason (either they were not catheterized, or they were catheterized and did not have high-grade obstructions, or for whatever reason they did not receive a stent). There is some suggestion in the literature that this group of patients might be candidates simply for warfarin, as this antithrombin can have efficacy similar to that of aspirin in managing these patients. In this case again the warfarin should be kept in the target range of INR 2 to 2.5, without aspirin. This is controversial, however, and there are not many data; furthermore, it is probably unlikely that most clinics would use just warfarin, but would instead use dual therapy, with aspirin plus warfarin, in the majority of these patients.
French WJ. Am J Med 2013; 126: 00-00.