Management of interventional therapy for patients with acute coronary syndrome and atrial fibrillation

Atrial fibrillation (AF) is a common arrhythmia following acute myocardial infarction and the overall percentage observed in previous studies ranges between 10 and 12%. Acute coronary syndrome (ACS) and AF are associated with a higher in-hospital and long-term mortality. Predisposing factors are higher bleeding complications, higher incidence of stroke, heart failure and cardiogenic shock. Access site complications can be significantly reduced using the transradial approach for PCI which improves the clinical outcome of these patients. Stroke is an important complication in patients hospitalized with ACS. The incidence of acute stroke in patients with ACS and AF varies between 0.5 and 1.3%. The increasing use of drug-eluting stents (DES) to minimize in-stent restenosis necessitates long-term dual antiplatelet therapy with aspirin plus a thienopyridine (at present most frequently clopidogrel) to reduce the risk of early and late stent thrombosis. Combined aspirin-clopidogrel therapy, however, is less effective in preventing stroke compared with oral anticoagulation (OAC) alone-and OAC alone is insufficient to prevent stent thrombosis. In patients with ACS and AF a triple therapy consisting of aspirin, clopidogrel and OAC (INR 2.0-2.5) is recommended according to the risk stratification (CHA(2)DS(2)-VASc score), the bleeding risk (HAS-BLED score), and the implanted stent (DES vs BMS). Triple therapy is associated with a higher bleeding risk and should be administered as briefly as necessary. Using beta-blockers, ACE inhibitors, direct current cardioversion or intravenous administration of amiodarone may reduce the incidence of AF and restore sinus rhythm which can reduce the duration of triple therapy.