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Combined anticoagulation and antiplatelet therapy in AF patients: why do we not follow guidelines?
  1. Axel Brandes
  1. Correspondence to Dr Axel Brandes, Department of Cardiology B, Odense University Hospital, Sdr. Boulevard 29, Odense C 5000, Denmark; axel.brandes{at}rsyd.dk

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While current European guidelines recommend oral anticoagulation treatment over antiplatelet therapy for the prevention of ischaemic stroke in patients with non-valvular atrial fibrillation (AF) with a 64% stroke risk reduction by warfarin treatment versus placebo and a 39% risk reduction versus aspirin,1 single or dual antiplatelet therapy is the guideline recommended first-line treatment strategy for patients with peripheral and/or coronary artery disease with and without intervention to prevent recurrences and major adverse cardiac events.2–7 Antiplatelet therapy is also recommended in patients with ischaemic stroke or transient ischaemic attack for secondary prevention unless related to AF or otherwise cardioembolic.8 Given these facts, there is a considerable potential for overlap of treatments when a patient suffers from AF and one of the other conditions. At least in patients with coronary artery disease and AF, the question, which is often raised in daily practice by many, is: Will this patient with AF and coronary atherosclerosis be sufficiently treated with an oral anticoagulant alone?

The situation becomes even more complex when patients with AF suddenly present with an acute coronary syndrome or stable coronary artery disease requiring placement of a stent or peripheral artery disease requiring interventional treatment. On the contrary, the same is true for patients undergoing antiplatelet therapy for coronary artery disease or peripheral artery disease who suddenly develop AF. In both situations, antithrombotic treatment with an oral anticoagulant combined with one or …

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