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The Melikian Center: Russian, Eurasian East European Studies

There is no clear preference for any of the currently available NOACs over VKA for patients with both AF and CAD. A joint European consensus document endorsed by the Heart Rhythm Society and Asia-Pacific Heart Rhythm Society refutes the concern that dabigatran may increase the risk of acute myocardial infarction. 11 Moreover, the large FDA Medicare analysis found no evidence of an increased risk of myocardial infarction in patients taking dabigatran compared with warfarin. 12

Based on our interpretation of available data, we suggest

Only limited data are available on the use of NOACs as antithrombotic therapy in patients with peripheral artery disease (PAD). Patients with PAD in ROCKET AF (5.9%) did not have a significantly higher risk of stroke or systemic embolism than did patients without PAD, and outcomes in patients treated with rivaroxaban and warfarin paralleled those in the trial as a whole. There was a significant interaction for major or non-major clinically relevant bleeding in patients with PAD treated with rivaroxaban compared with warfarin (hazard ratio, HR: 1.40, 95% confidence interval, CI: 1.06–1.86) and those without PAD (HR: 1.03, 95% CI: 0.95–1.11; interaction P = 0.037). 13 Randomized trials of edoxaban and rivaroxaban in patients with PAD are currently underway. 14

Based on our interpretation of available data we suggest:

Patients with AF and an acute coronary syndrome or stable CAD may require percutaneous coronary intervention with stenting. In these patients, the need for OAC treatment to prevent stroke and for dual antiplatelet therapy to prevent stent thrombosis must be balanced against the increased risk of bleeding (particularly intracranial haemorrhage) with dual or triple antithrombotic therapy.

The use of VKAs in this setting has been the subject of observational studies and one completed randomized trial, 15 and is currently under investigation in comparison with NOACs in additional trials. All phase III trials of NOACs allowed the concomitant use of aspirin (≤100 mg/day) for patients undergoing percutaneous coronary interventions, but only the RE-LY trial included a substantial number of patients on concomitant clopidogrel with or without aspirin. 10 Ongoing trials will provide additional data for NOACs or warfarin in combination with aspirin and/or P2Y12 inhibitors (clopidogrel, prasugrel, or ticagrelor) (REDUAL-PCI for dabigatran NCT02164864, PIONEER-AF-PCI for rivaroxaban NCT01830543, AUGUSTUS for apixaban NCT02415400).

Management of these patients was recently addressed in the joint European consensus document. 11 The document suggested a period of triple therapy (OAC plus aspirin plus clopidogrel), followed by a period of dual therapy (OAC plus single antiplatelet agent, preferably clopidogrel). Once the patient is stable, after 1 year, an OAC alone can be given. When an OAC is prescribed, this can be either controlled VKA therapy [time in therapeutic range (TTR) of >70%; preferred international normalized ratio (INR) range 2.0–2.5] or an NOAC. When an NOAC is combined with dual antiplatelet therapy, the lower dose tested for stroke prevention in AF is recommended.

Newer SPECT techniques with ECG gating improve diagnostic accuracy in various patient populations, including women, diabetics, and elderly patients [ 23 ]. Adding information from a simultaneously performed calcium score using MDCT may further increase the accuracy [ 24 ].

Cardiac MRI stress testing with pharmacological stressors can be used to detect wall motion abnormalities induced by dobutamine infusion or perfusion abnormalities induced by adenosine. Cardiac MRI has been applied only recently in clinical practice and therefore fewer data have been published compared with other established non-invasive imaging techniques [ 12 ].

A recent meta-analysis showed that stress-induced wall motion abnormalities from MRI had a sensitivity of 83% and a specificity of 86% in patient-based analysis, and perfusion imaging demonstrated 91% sensitivity and 81% specificity [ 25 ]. When evaluated prospectively at multiple sites, the diagnostic performance of stress perfusion MRI shows similarly high sensitivity but lower specificity.

MDCT can be used for perfusion imaging, but data obtained in clinical settings are scarce.

Studies with myocardial perfusion PET have reported excellent diagnostic capabilities in the detection of CAD. The comparisons of PET perfusion imaging have also favoured PET over SPECT [ 26 ].

Meta-analysis of data obtained with PET demonstrated 92% sensitivity and 85% specificity for CAD detection, superior to myocardial perfusion SPECT. Myocardial blood flow in absolute units (mL/g/min) measured by PET further improves diagnostic accuracy, especially in patients with MVD, and can be used to monitor the effects of various therapies.

The combination of anatomical and functional imaging has become appealing because the spatial correlation of structural and functional information of the fused images may facilitate a comprehensive interpretation of coronary lesions and their pathophysiological relevance. This combination can be obtained either with image coregistration or with devices that have two modalities combined (MDCT and SPECT, MDCT and PET).

Single-centre studies evaluating the feasibility and accuracy of combined imaging have demonstrated that MDCT and perfusion imaging provide independent prognostic information. No large or multicentre studies are currently available.

In common practice, many patients with intermediate or high pretest CAD likelihood are catheterized without prior functional testing. When non-invasive stress imaging is contraindicated, non-diagnostic, or unavailable, the measurement of FFR or coronary flow reserve is helpful. Even experienced interventional cardiologists cannot predict accurately the significance of most intermediate stenoses on the basis of visual assessment or quantitative coronary angiography [ 27 , 28 ]. Deferral of PCI [ 15 , 28 ] or CABG [ 27 ] in patients with FFR > 0.80 is safe and clinical outcome is excellent. Thus, FFR is indicated for the assessment of the functional consequences of moderate coronary stenoses when functional information is lacking.

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