Christian T. Ruff, MD, MPH, on Treating Comorbid AF and CAD

Atrial fibrillation (AFib) and coronary artery disease (CAD) are common comorbidities. However, treating patients with both conditions is often misunderstood.

At the InterPro AFib Forum, Christian T. Ruff, MD, MPH, who is the director of general cardiology and assistant professor of medicine at Brigham and Women's Hospital in Boston, spoke about the management of antithrombotic therapy in patients with comorbid AFib and CAD.

Cardiology Consultant caught up with Dr Ruff after his session with a few follow-up questions.

CARDIOLOGY CONSULTANT: Which antithrombotic therapies are indicated for patients with AFib and CAD? What are the alternatives if patients fail therapy or are nonadherent?

Christian T. Ruff: Multiple clinical trials have demonstrated that anticoagulation is more effective than antiplatelet therapy for prevention of strokes in patients with AFib. In CAD, we traditionally use antiplatelet agents, though anticoagulants are effective in reducing myocardial infarction (MI). For patients with AFib and stable CAD, we often use anticoagulation alone since it is effective for both, and combination antithrombotic regimens (anticoagulant + antiplatelet) significantly increase the risk of major bleeding. For patients with recent MI or stenting, we often will do a short duration of combination therapy (either triple therapy with aspirin, P2Y12 inhibitor, and anticoagulant or P2Y12 inhibitor + anticoagulant) for several weeks or months.

CARDIO CON: Are there any contraindications for women who are pregnant? Is this patient population managed any differently?

CTR: There are no data on the use of non-vitamin K anticoagulants (NOACs) in pregnant women, and warfarin cannot be used in the first trimester due to the risk of birth defects. Antiplatelet agents can be used in pregnancy. Since AFib and CAD are generally diseases of the elderly, it would be quite rare to have a pregnant patient with both of these conditions.

CARDIO CON: Can you give us an example of a challenging patient you’ve encountered? What did you do in that situation?

CTR: A patient with AFib with a recent heart attack who had a history of several serious gastrointestinal bleeding episodes requiring ICU admissions and transfusions presented to my office. The patient was prescribed a NOAC + P2Y12 inhibitor with no period of triple therapy (aspirin + P2Y12 inhibitor + anticoagulant).

CARDIO CON: What are the top 3 questions you receive from your peers about managing antithrombotic therapy in patients with AFib and CAD? How do you answer them?

CTR: (1) Is it effective to just use an anticoagulant in patients with AF and CAD? Yes, especially in patients at least 1 year out from MI or stenting. (2) Should you use clopidgrel or the more potent P2Y12 inhibitors prasugrel or ticagrelor if using in combination with anticoagulant? Given the increased risk of bleeding with more potent P2Y12 inhibitors, it is generally safer to treat with clopidogrel as the anticoagulant, and it will help reduce risk of MI. (3) Which anticoagulant should you use if using in combination with antiplatelet agents? The NOACs are associated with 50% fewer life-threatening bleeding events than warfarin, so they are preferred when using in combination with antiplatelet agents.