Does acetylsalicylic acid have a future in patients with A-fib and ACS?

Patients with atrial fibrillation receive anticoagulation therapy as standard. This is supplemented by dual platelet inhibition in the presence of acute coronary syndrome (ACS). The main concern of doctor and patient is the risk of severe bleeding events. What combinations of drugs are possible here? Is acetylsalicylic acid (ASA) an option in combined anticoagulation therapy for these patients?

ASA as an option in combined anticoagulation therapy

Patients with atrial fibrillation receive anticoagulation therapy as standard. This is supplemented by dual platelet inhibition in the presence of acute coronary syndrome (ACS). The main concern of doctor and patient is the risk of severe bleeding events. What combinations of drugs are possible here? Is acetylsalicylic acid (ASA) an option in combined anticoagulation therapy for these patients?

About 15% of patients with A-fib develop acute coronary syndrome (ACS). Current ESC guidelines recommend oral anticoagulation in A-fib to reduce the risk of stroke. The only exceptions are men with a CHA2DS2-VASc of 0 and women with a score of 1. The long-term recommendation of the guideline for the prevention of ACS recommends dual platelet inhibition for up to 12 months after an event.

For doctor and patient, this combination therapy of platelet inhibition and anticoagulation means a much higher risk of bleeding. So what to do? What combination possibilities are there for the treatment of these patients?

The agony of choice

Due to a large number of available drugs, there are currently approximately 2.8 million possible therapy combinations for the antithrombotic treatment of cardiovascular patients, all of which may have varying degrees of bleeding risk.

The decision as to which combination is best for a specific patient is made even more difficult by the fact that no reliable study data are available on this subject to date. Nevertheless, some studies are already underway, so that the near future should provide the first answers here.

PIONEER AF-PCI (rivaroxaban) and RE-DUAL PCI (dabigatran) have already been completed. The results for AUGUSTUS ACS/PCI (Apixaban) and ENTRUST AF-PCI (Edoxaban) are expected in 2019 and 2020, respectively.

RCTs give a clear vote for NOACs

From the study data available so far it can be seen:

• The combination of ASA, P2Y12 inhibitors and OAC (oral anticoagulation) increase the risk of bleeding in anticoagulation therapy.
• A risk reduction strategy could be to shorten the duration of dual platelet inhibition in patients requiring an OAC. In addition, clopidogrel could be used instead of a more potent P2Y12 inhibitor.
• PIONEER AF-PCI and RE-DUAL PCI propose dual therapy using NOACs combined with platelet inhibition. Alternatively, a triple combination with NOAC and dual plate inhibition could be used. In both cases, fewer bleeding events occur than in (Vitamin K Antagonist) VKA-based triple therapy. Cave: However, the results of both studies should be interpreted with caution. On the one hand, only patients with PCI were included. On the other hand, it is unclear whether the reduction of the bleeding risk in RE-DUAL resulted from the use of dabigatran or from the omission of ASA. It is hoped that the AUGUSTUS study will be able to answer the question of whether or not ASA in combination with anticoagulation and platelet inhibition offers an additional benefit in the next two years.

Bottom line

Patients with A-fib and simultaneously existing ACS have an increased tendency to bleed due to therapy. Recommendations for the optimal treatment combination of anticoagulation and platelet inhibition cannot currently be given due to lack of study data.

However, data from the PIONEER and RE-DUAL studies suggest that a combination involving NOACs could reduce the risk of bleeding in these patients. The results of the AUGUSTUS study in the coming years will show what additional role ASA plays in this. However, it should already be noted that the combination of ASA, P2Y12 inhibitors and OAC leads to an increased risk of bleeding and is therefore not recommended.

Source:
"Atrial fibrillation patients who develop acute coronary syndrome: is there a role for ASA?" (Organizer: Bristol-Myers Squibb and Pfizer Alliance), 27.08.2018, ESC Munich