ACS with Atrial Fibrillation — EECC MCQ

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ModerateCoronary Artery DiseaseACS with Atrial FibrillationEECC

A 72-year-old man with atrial fibrillation, hypertension, and diabetes mellitus is admitted with NSTEMI. He undergoes PCI with a drug-eluting stent to the mid-LAD. He is currently on edoxaban 60 mg once daily for atrial fibrillation. His CHA2DS2-VA score is 4. What is the most appropriate antithrombotic regimen at discharge?

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Correct answer: B — Edoxaban plus clopidogrel; aspirin for the first 7 days

Explanation lettering: D = shown as B · E = shown as D · B = shown as E

Per the 2023 ESC ACS Guidelines, in patients with ACS requiring OAC (e.g. for AF), the recommended strategy is early cessation of aspirin (within 1 week) with continuation of a DOAC plus clopidogrel (dual pathway therapy) for up to 12 months. This is based on WOEST, PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS trials. Prolonged triple therapy (A) carries excess bleeding risk. Ticagrelor with a DOAC (C) is not recommended due to increased bleeding risk. Warfarin-based triple therapy with ticagrelor (D) has the highest bleeding risk. Aspirin with DOAC without P2Y12 inhibitor (E) provides inadequate stent protection. Apply this conclusion only to the clinical circumstances stated, with appropriate specialist review, contraindication checks, shared decision-making and follow-up. Reassess if the physiology, treatment response or competing risk changes. The competing options would require a different haemodynamic profile, diagnosis, procedural indication or risk balance from the one described here.

Reference: ESC (2023): Guidelines for the Management of Acute Coronary Syndromes: https://www.nice.org.uk/guidance/ng109/chapter/recommendations