Written by Peter Liu
Spoon Feed
Oral anticoagulant (OAC) monotherapy results in less bleeding and similar thrombotic outcomes for patients with stable coronary artery disease (CAD) and atrial fibrillation (AF) compared to OAC + single antiplatelet (SAPT) therapy.
Not all patients with CAD benefit from aspirin
Antiplatelet therapy benefits patients with stable CAD, acute coronary syndrome (ACS), or percutaneous coronary intervention (PCI). However, when there is an indication for oral anticoagulation, such as AF, the balance between bleeding risk and antithrombotic benefit for SAPT on top of OAC remains uncertain. Current CAD guidelines suggest the following: “In patients with [CAD] who require oral anticoagulation, DOAC monotherapy may be considered if there is no acute indication for concomitant antiplatelet therapy” (Class: 2b, LOE: C-LD).
Today’s meta-analysis assessed whether oral anticoagulation (OAC) monotherapy is as effective and safer than OAC plus single antiplatelet therapy (SAPT) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). Four randomized controlled trials (N=4,092) were included. No significant differences were found in ischemic outcomes (HR 0.90; 95%CI 0.72-1.12), but OAC monotherapy significantly reduced major bleeding risk (3.3% vs 5.7%; HR 0.59; 95%CI 0.44-0.79). This supports OAC monotherapy over OAC + SAPT for patients with AF and stable CAD. This meta-analysis has several limitations. First, edoxaban and rivaroxaban are the major OACs represented in the trials, and apixaban is not represented at all. Second, the patients were quite heterogeneous both in their CAD and what APT agent they were on (roughly two-third aspirin, and one-third P2Y12 inhibitor) making it difficult to assess which thrombotic risk factors impacted selection of APT therapy. I agree with the AHA that there are “limited data to support the recommendation.”
How does this change my practice?
Generally, this supports deprescribing aspirin in patients with stable CAD who are on OAC for another indication. Exceptions should be made for patients who have low bleeding risk and high thrombotic risk (not well-studied), and patients with acute antithrombotic therapy indications (e.g. recent ACS or PCI).
Source
Anticoagulation and Antiplatelet Therapy for Atrial Fibrillation and Stable Coronary Disease: Meta-Analysis of Randomized Trials. J Am Coll Cardiol. 2025 Jan 17:S0735-1097(25)00071-3. doi: 10.1016/j.jacc.2024.12.030. Epub ahead of print. PMID: 39918465
