Antithrombotic in atrial fibrillation and coronary artery disease – Does less mean more?

In the treatment of patients with chronic coronary syndrome, the use of antiplatelets in the form of aspirin is a class 1 indication in the prevention of future thrombotic events.1 Similarly, oral anticoagulation (OAC) has a class 1 indication for patients with atrial fibrillation (AF) and a CHA2DS2-VASc (congestive heart failure) score of 2 or more in males and a score of 3 or more in females in the form of a non–vitamin K antagonist oral anticoagulant (NOAC) for stroke prevention.2 However, the optimal choice of long-term antithrombotic therapy in patients with AF in the presence of coronary artery disease (CAD) has been subject to much debate. Striking the right balance between thrombotic and bleeding risk with different monotherapy or combination therapy with OAC and antiplatelet(s) remains a difficult task requiring the understanding of the dynamic nature and continual assessment of nonmodifiable and modifiable bleeding and thrombotic risk factors.