Stable coronary patients with atrial fibrillation: when the kidneys tip the balance

The management of atrial fibrillation (AF) in patients with concomitant coronary artery disease (CAD) has progressively shifted from “more is safer” to “simpler is better”, particularly once CAD is stable. Recent studies have shown that anticoagulation alone, as compared to anticoagulation plus antiaggregation, reduces bleeding risk without increasing ischaemic risk in these patients.123 In surprising ways, the addition of aspirin to anticoagulation was even associated with excess mortality in the AQUATIC trial.4 Yet a common clinical hesitation persists: when a patient is older, comorbid, and has a history of CAD, can clinicians truly step back from antiplatelet therapy?

Chronic kidney disease (CKD) is a widespread comorbidity that further complicates the choice of antithrombotic therapy. Renal dysfunction simultaneously increases thrombotic risk and amplifies bleeding liability, while also affecting the level of exposure to direct oral anticoagulation.

In this issue of EuroIntervention, Lee et al, the authors of the prespecified EPIC-CAD trial,5 directly address the matter of whether kidney function modifies the net clinical benefit of edoxaban monotherapy compared with edoxaban plus a single antiplatelet agent in patients with...