Antithrombotic therapy in atrial fibrillation patients with coronary artery disease: shifting paradigm to a "less is more" concept regimen.

Dual antiplatelet therapy (DAPT) reduces the risk of ischemic events, including stent thrombosis, in patients undergoing percutaneous coronary intervention (PCI), while oral anticoagulants are superior to antiplatelet therapy for preventing thromboembolic events, including ischemic stroke, in patients with atrial fibrillation (AF). Reportedly, the AF population accounts for approximately 5 to 10% of patients undergoing PCI. From a theoretical viewpoint, combination therapy of DAPT and oral anticoagulation was previously recommended in patients with AF undergoing PCI. However, long-term triple therapy carries the risk of major bleeding. Recent clinical trials (WOEST, PIONEER AF-PCI, RE-DUAL PCI, AUGUSTUS, and ENTRUST AF-PCI trials) demonstrated the advantage of dual therapy with an oral anticoagulant (warfarin or direct oral anticoagulant) plus an antiplatelet agent, which decreased the rate of major bleeding in the acute phase in AF patients who underwent PCI. These results affected guidelines, which now recommend that the duration of triple therapy should be limited, and dual therapy should be considered an alternative regimen when considering the bleeding risk. The current guidelines recommend monotherapy with an oral anticoagulant after 12 months of combination therapy, or in patients with AF and stable coronary artery diseases not requiring intervention. However, this approach has yet to be validated by randomized, controlled trials. Recently, the AFIRE trial demonstrated that rivaroxaban monotherapy was noninferior to dual therapy in terms of efficacy and superior in terms of safety in this population. Accumulating evidence demonstrates that there has been a paradigm shift in antithrombotic therapy to a "less is more" regimen. This article reviews current evidence and focuses on the optimal approach to antithrombotic treatment in patients with AF undergoing PCI in acute and chronic/stable phases.