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Complex antithrombotic combinations: how to find the perfect blend?
  1. Mark R Thomas1,
  2. Erik Lerkevang Grove2,
  3. Paulus Kirchhof1
  1. 1 Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
  2. 2 Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
  1. Correspondence to Dr Mark R Thomas, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK; m.r.thomas{at}

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Patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) present a frequent clinical dilemma if they also have atrial fibrillation (AF). They require antiplatelet therapy to prevent stent thrombosis and recurrent myocardial infarction (MI), but also require anticoagulation as stroke prophylaxis for AF.1 However, the optimal combination of aspirin, platelet P2Y12 inhibitor and anticoagulant is still unknown, and a one-size-fits-all approach may never be possible. We now have five randomised controlled trials on this topic—so what have they taught us? We have learnt that discontinuation of aspirin significantly reduces the risk of major bleeding,2 with a possible trend towards a small increase in risk of recurrent MI and stent thrombosis.3 We have also learnt that apixaban,2 and likely all of the current non-vitamin K oral anticoagulants (NOAC),3 4 reduce the risk of major bleeding compared with warfarin in this setting.

So what do we have left to learn? One major outstanding issue is the optimal choice of platelet P2Y12 inhibitor. In patients without AF, ticagrelor and prasugrel have largely superseded clopidogrel in the treatment of ACS. Compared with clopidogrel, …

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  • Contributors MRT produced the first draft of the manuscript in collaboration with ELG and PK.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MRT has received research grants from Rigel Pharmaceuticals and Novartis and consultancy fees from Cytosorbents. ELG has received speaker honoraria or consultancy fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Pfizer, MSD, Portola Pharmaceuticals and Roche. He has received research grants from Boehringer Ingelheim. PK has received research support from the British Heart Foundation, the European Union, the German Centre for Cardiovascular Research, the Leducq Foundation and the Medical Research Council, and from several drug and device companies active in atrial fibrillation; he has also received honoraria from several such companies, including Bayer, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, and Daiichi Sankyo. He is listed as an inventor on two patents held by the University of Birmingham (Atrial Fibrillation Therapy WO 2015140571; Markers for Atrial Fibrillation WO 2016012783).

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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