Lakshmi Kattamuri: Contemporary Evidence on Antithrombotic Therapy in AF and Chronic Coronary Disease
Lakshmi Kattamuri, Cardiology Fellow at West Virginia University, shared a post on X about a recent article she and her colleagues co-authored, published in Current Vascular Pharmacology, adding:
“Does your patient with AF plus prior PCI really need lifelong aspirin?
More antithrombotic therapy is not equal to better outcomes.
Our new article in Current Vascular Pharmacology examines the evidence from landmark trials.
A practical Cardio Twitter thread the clinical dilemma AF plus CAD presents two competing risks:
- Bleeding from combined antithrombotic therapy
- Ischemic events, including stent thrombosis.
The key question: when can we safely discontinue antiplatelet therapy?
Early after ACS/PCI
Four landmark trials changed practice:
- WOEST (2013)
- PIONEER AF-PCI (2016)
- RE-DUAL PCI (2017)
- AUGUSTUS (2019)
Less bleeding with dual therapy.
Early aspirin withdrawal in most patients.
Individualize for stent thrombosis risk.
AUGUSTUS: The Aspirin question.
Among patients with AF plus recent ACS/PCI receiving a P2Y12 inhibitor:
Major/CRNM bleeding: 16.1 percent with aspirin versus 9.0 percent with placebo HR 1.89!
Aspirin increased bleeding substantially without a significant reduction in overall ischemic events.
What about stable CAD?
Beyond 1 year after PCI, the evidence increasingly favors OAC monotherapy.
- AFIRE
- OAC-ALONE
- PRAEDO-AF
- EPIC-CAD
Collectively: less bleeding with OAC alone, without a demonstrated increase in major ischemic outcomes.
AQUATIC (2025): A striking finding.
Even in high-atherothrombotic-risk patients with prior stenting on long-term OAC:
- CV composite: 16.9 percent versus 12.1 percent
- Major bleeding: 10.2 percent versus 3.4 percent
- All-cause death: 13.4 percent versus 8.4 percent
All higher with aspirin versus placebo!
Practical takeaway.
For most patients with AF plus stable CAD requiring OAC:
- >1 year after PCI: OAC alone is generally preferred.
- Avoid indefinite aspirin without a compelling indication.
- Reassess ischemic and bleeding risks.
Prior stent thrombosis warrants individualized assessment.”
Title: Antithrombotic Therapy in Patients with Chronic Coronary Disease on Anticoagulation: Evidence from Contemporary Trials
Authors: Sukhila Reddy, Lakshmi Kattamuri, Muhammad Asif, Debabrata Mukherjee
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