Antithrombotic management in atrial fibrillation patients following percutaneous coronary intervention: A clinical review

Abstract

Patients with atrial fibrillation (AF) often develop acute coronary syndrome and undergo percutaneous coronary intervention (PCI), and vice versa. Acute coronary syndrome and PCI mandate the use of dual antiplatelet therapy, while oral anticoagulation is recommended in patients with AF to mitigate thromboembolic risks. Clinical evidence concerning antithrombotic treatment in patients with AF and PCI has been accumulated, but when combined, the therapeutic strategy becomes complex. Although triple therapy, a combination of oral anticoagulation with dual antiplatelet therapy, has been used for patients with AF undergoing PCI as an initial antithrombotic strategy, less intensive regimens may be associated with a lower rate of bleeding without an increased risk in thrombotic events. This narrative review article summarizes currently available evidence of antithrombotic therapy in patients with AF undergoing PCI.

INTRODUCTION

Atrial fibrillation (AF) is a common cardiac rhythm disturbance leading to heart failure and thromboembolic events. ¹ The estimated prevalence of AF in Japan and East Asia was approximately 1000 cases per 100 000 population in 2020, projected to rise for the next decades globally. ¹ In patients with AF, concomitant coronary artery disease (CAD) is often present, and vice versa. About 20% of patients with AF reportedly develop acute coronary syndrome or undergo percutaneous coronary intervention (PCI). ² Although antithrombotic therapies are a cornerstone of the management of patients with AF and those undergoing PCI to prevent thrombotic and ischemic events, the therapeutic regimens become complex when both conditions coexist. Dual antiplatelet therapy (DAPT) is indicated, at least as an initial antiplatelet regimen, for patients undergoing PCI to mitigate the risk of myocardial infarction and stent thrombosis, ³ while oral anticoagulation (OAC) is beneficial in reducing thromboembolic events (e.g. ischemic stroke) to a greater extent than DAPT in patients with AF. ⁴ Triple antithrombotic therapy, a combination of DAPT plus an OAC, has been used in clinical practice but is associated with an increased risk of serious bleeding events. ⁵ According to several randomized control trial (RCT) results, guidelines have been updated, showcasing the “less is more” concept. ⁶ This narrative review article briefly summarizes the current evidence concerning antithrombotic therapy in patients with AF undergoing PCI.

CLINICAL TRIAL RESULTS

Since the clinical efficacy of DAPT as compared with OAC was established in RCTs in the late 1990s, DAPT consisting of aspirin and a P2Y12 inhibitor has been the cornerstone of antithrombotic management in patients undergoing PCI, ³ while OAC with vitamin K antagonist (VKA) was superior over DAPT in reducing ischemic events among patients with AF. ⁴ In recent decades, direct oral anticoagulation (DOAC) has been shown to have a favorable risk–benefit profile as compared to VKA, particularly in the reduction of intracranial hemorrhage. ⁷ Thus, a combination of DAPT with OAC may be “theoretically” necessary for patients with AF undergoing PCI. Yet, the clinical effectiveness of this intensive antithrombotic strategy has not been well-proven. The term “triple (antithrombotic) therapy” indicates a combination of OAC (VKA or DOAC) plus DAPT (aspirin and a P2Y₁₂ inhibitor), while “dual (double) therapy” includes an OAC with single antiplatelet therapy (SAPT) (aspirin or a P2Y₁₂ inhibitor). ⁸ In addition, OAC monotherapy is a regimen of single OAC (VKA or DOAC) with no antiplatelet agents.

To date, several RCTs have shown that triple therapy is associated with an increased risk of major bleeding events in patients undergoing PCI with an OAC indication (Table 1). ^9–16 A meta-analysis confirmed that DOAC-based dual (double) therapy after periprocedural triple therapy for 3 to 14 days resulted in a lower risk of major and intracranial hemorrhages as compared with VKA-based triple therapy for 1 to 12 months, although the less potent antithrombotic regimen (i.e. dual therapy) was probably associated with a higher risk of stent thrombosis. ¹⁷ However, dual therapy may be reasonable because of the relatively low event risk of stent thrombosis rather than major bleeding in this patient population. Of note, Pivotal RCTs in Table 1 such as the WOEST, PIONEER AF-PCI, RE-DUAL PCI, AUGUSTUS, and ENTRUST-AF PCI trials randomized patients to either the dual or triple antithrombotic regimen 3 to 14 days after PCI, during which triple therapy was applied even to the experimental dual therapy group. Thus, whether triple therapy, aspirin in particular, can be safely omitted at the time of PCI remains unclear. Another recent meta-analysis reinforced that periprocedural DAPT was better in terms of bleeding outcomes as compared to short- (4–6 weeks) or long-term (≥3 months) DAPT on top of OAC in patients undergoing PCI with an indication for anticoagulation. ¹⁸ Beyond 12 months after PCI, lifelong OAC with no antiplatelet therapy has been recommended in the guidelines according to the historical data with VKA. In this context, two RCTs from Japan, the OAC-ALONE and AFIRE trials, shed light on the evidence gap (Table 2). The OAC-ALONE was the first RCT that included patients with AF and stable CAD beyond 1 year after coronary stenting. ¹⁹ Although this study was prematurely terminated as a result of slow enrollment and resulted in insufficient statistical power, a signal of less frequent major bleeding events in the OAC monotherapy group than in the combined OAC plus SAPT group was found. ¹⁹ The subsequent AFIRE trial demonstrated that rivaroxaban monotherapy was non-inferior (and indeed superior) to the combined antithrombotic therapy of rivaroxaban plus SAPT in both ischemic and bleeding endpoints in patients with AF who had undergone PCI or coronary artery bypass grafting >1 year earlier or who had angiographically confirmed CAD. ²⁰ Although the underlying mechanism of fewer ischemic events in the rivaroxaban monotherapy group in the trial is uncertain, a sub-analysis from the AFIRE showed that ischemic outcomes were likely to occur soon after a major bleeding event, which were presumably associated with a decreased threshold for myocardial ischemia and heart failure, potential harm of red blood cell transfusions, and discontinuation of antithrombotic therapy following bleedings. ²¹ Thus, it is conceivable that OAC monotherapy beyond 1 year after PCI should be a default antithrombotic regimen in patients with AF and PCI. Probably because of recent advances in medical therapy and PCI technologies, ^22–63 ischemic and thrombotic risks after interventional procedures have been declined, while bleeding events have been increased, ⁶⁴ leading to the “less is more” concept in antithrombotic regimens in the current era.

TABLE 1 Key randomized trials of antithrombotic therapy in patients with indications for SAPT and OAC.

	Publication year	Sample size	AF	PCI	Abbreviated DAPT	Prolonged DAPT	Tested OAC	Results
WOEST 9	2013	573	69%	100%	Periprocedural DAPT followed by clopidogrel	≥1 m (BMS) or ≥12 m (DES)	VKA	Dual therapy reduced bleeding and death than TT
ISAR-TRIPLE 10	2015	614	84%	100%	6 w DAPT followed by aspirin	6 m DAPT (aspirin + clopidogrel)	VKA	6 w TT was not superior to 6 m TT in net clinical outcomes
PIONEER AF-PCI 11	2016	2124	100%	100%	Periprocedural DAPT only in the DOAC arm	1–12 m only in the VKA arm	Rivaroxaban vs. VKA c	Dual therapy with low-dose rivaroxaban reduced bleeding events than VKA-TT
RE-DUAL PCI 12	2017	2725	100%	100%	Periprocedural DAPT only in the DOAC arm	1–3 m only in the VKA arm	Dabigatran versus VKA	Dual therapy with dabigatran reduced bleeding events than VKA-TT
AUGUSTUS 13	2019	4614	100%	76%	Periprocedural DAPT followed by P2Y12i	6 m DAPT (aspirin + P2Y12i)	Apixaban versus VKA	Dual therapy with apixaban reduced bleeding events than VKA-TT
ENTRUST-AF PCI 14	2019	1506	100%	100%	Periprocedural DAPT only in the DOAC arm	1–12 m only in the VKA arm	Edoxaban versus VKA	Edoxaban-based dual therapy was non-inferior to VKA-based TT
SAFE-A 15	2020	208 a	100%	100%	1 m DAPT (aspirin + P2Y12i) followed by SAPT	6 m DAPT (aspirin + P2Y12i)	Apixaban	Bleedings were non-significantly fewer in abbreviated DAPT group
MASTER-DAPT 16	2021	1666 b	84%	100%	1 m DAPT (aspirin + P2Y12i) followed by SAPT	≥3 m DAPT (aspirin + P2Y12i) followed by SAPT	VKA or DOAC	Bleedings were non-significantly fewer in abbreviated DAPT group

TABLE 2 Key randomized trials of antithrombotic therapy in patients with indications for SAPT and OAC at a chronic phase.

	Publication year	Sample size	AF	PCI	Experimental arm	Control arm	Tested OAC	Results
OAC-ALONE 19	2018	690 a	100%	100%	OAC monotherapy	OAC plus SAPT	VKA or DOAC	Non-inferiority of OAC alone strategy was not established
AFIRE 20	2019	2215	100%	71%	Rivaroxaban monotherapy	Rivaroxaban plus SAPT	Rivaroxaban	Rivaroxaban monotherapy reduced ischemic and bleeding events

GUIDELINE RECOMMENDATIONS AND FUTURE PERSPECTIVES

According to the clinical evidence, recent guidelines and consensus documents recommend triple therapy for 1 to 30 days after PCI in patients with AF, followed by dual therapy (OAC plus a P2Y12 inhibitor) for up to 1 year and OAC monotherapy thereafter (Figure 1). ^8,65–69 Discontinuation of aspirin within 7 days or at discharge is indicated in the recommendations, although triple therapy for up to 30 days is allowed based on individual ischemic and bleeding risks in AF patients undergoing PCI. ⁸ In terms of intraprocedural anticoagulation in patients undergoing PCI who have an indication for OAC, activated clotting time >250 s with the use of unfractionated heparin during PCI is recommended. ⁷⁰ Recent trials have demonstrated that SAPT with a P2Y12 inhibitor rather than aspirin was associated with lower ischemic events after PCI, ^71,72 and a P2Y12 inhibitor may be preferable over aspirin as a part of dual therapy with OAC. ⁶⁹ Additionally, DOAC is recommended over VKA to reduce intracranial hemorrhage. ^8,69 Lifelong OAC monotherapy is indicated 1 year after PCI, but if the thrombotic risk is low, OAC alone beyond 6 months may be considered. ⁸ The current recommendations are summarized in Figure 1. Of note, accurate ischemic and bleeding risk stratification is relevant in clinical decision-making in antithrombotic therapy in patients undergoing PCI with AF, although no risk-scoring systems have been established in this context. From a PCI perspective, the criteria of Academic Research Consortium for High Bleeding Risk (ARC-HBR) are a guideline-recommended tool and used globally for the bleeding risk stratification, while the Japanese guidelines recommend domestically modified criteria of ARC-HBR in patients undergoing PCI. ⁶⁹ However, whether antithrombotic management guided by the ARC-HBR criteria improves clinical outcomes in patients undergoing PCI is unclear. In terms of ischemic risk stratification, the Japanese guidelines indicate some scoring-systems including the PARIS and CREDO-Kyoto thrombotic risk scores to guide antithrombotic regimens after PCI. ⁶⁹ Yet, these scoring-systems may not be widely employed in daily clinical practice. At present, ischemic and bleeding risk stratification using such risk scores may be reasonable, but future studies are warranted.

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Given that recent trials investigating “aspirin-free” regimens from the beginning of PCI have shown favorable results of the novel antithrombotic strategy, aspirin as a part of triple therapy may be safely omitted, at least in a setting of low thrombotic risk. ^73–75 Currently, aspirin-free SAPT with a P2Y12 inhibitor (clopidogrel, prasugrel, and ticagrelor) is being tested globally in patients with acute coronary syndrome, including the NEO-MINDSET (NCT04360720), LEGACY (NCT05125276), and PREMIUM (NCT05709626) trials. ⁷⁶ If these studies unveil the clinical effectiveness of aspirin-free SAPT in an acute setting, no DAPT strategy may become a guideline-recommended antiplatelet regimen in patients undergoing PCI. In AF patients undergoing PCI, the MATRIX-2 (NCT05955365) and OPTIMA-AF (jRCTs051190053) trials are currently ongoing to evaluate the safety and efficacy of shorter duration of dual therapy consisting of SAPT with a P2Y12 inhibitor plus DOAC for 1 month, followed by DOAC monotherapy, as compared to 6- or 12-month dual therapy. ^76,77 Aspirin is discontinued immediately after PCI in the experimental arms in the MATRIX-2 and OPTIMA-AF trials, ^76,77 suggesting the clinical feasibility of minimum duration of DAPT (i.e. only at the time of PCI) in patients with AF and an indication for OAC. These trial results will shape our understanding of antithrombotic therapy in AF patients undergoing PCI, potentially leading to the regimen of no or 1-day DAPT with DOAC, followed by dual therapy with a P2Y12 inhibitor plus DOAC for 1 month, and DOAC monotherapy thereafter (Figure 1). Furthermore, it is conceivable that left atrial appendage occlusion and resection will also play a significant role in this field. ^78–81

CONCLUSIONS

Although the antithrombotic regimen should be balanced depending on ischemic and bleeding risks, enthusiastic efforts on antithrombotic therapy in recent decades have established the “less is more” concept in AF patients undergoing PCI. Future investigations will provide better guidance for antithrombotic regimens and standards for this patient population.

CONFLICT OF INTEREST STATEMENT

All conflicts of interest are declared by authors in the manuscript.

DISCLOSURES

Yuichi Saito received lecture fees from Daiichi Sankyo. Yoshio Kobayashi received lecture fees from Abbott Medical Japan and Daiichi Sankyo and research grants from Abbott Medical Japan, Win International, Otsuka Pharmaceutical, Boehringer Ingelheim, Nipro, and Japan Lifeline.

References

Brundel B, Ai X, Hills MT, Kuipers MF, Lip GYH, de Groot NMS. Atrial fibrillation. Nat Rev Dis Primers. 2022;8:21.

Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893–2962.

Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK, et al. A clinical trial comparing three antithrombotic‐drug regimens after coronary‐artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med. 1998;339:1665–1671.

Connolly S, Pogue J, Hart R, Pfeffer M, Hohnloser S, Chrolavicius S, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the atrial fibrillation clopidogrel trial with Irbesartan for prevention of vascular events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367:1903–1912.

Hansen ML, Sørensen R, Clausen MT, Fog‐Petersen ML, Raunsø J, Gadsbøll N, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010;170:1433–1441.

Gue YX, Gorog DA, Lip GYH. Antithrombotic therapy in atrial fibrillation and coronary artery disease: does less mean more? JAMA Cardiol. 2022;7:794–795.

Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta‐analysis of randomised trials. Lancet. 2014;383:955–962.

Capodanno D. Triple therapy, dual therapy, and modulation of anticoagulation intensity. JACC Cardiovasc Interv. 2021;14:781–784.

Dewilde WJM, Oirbans T, Verheugt FWA, Kelder JC, De Smet BJGL, Herrman J‐P, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open‐label, randomised, controlled trial. Lancet. 2013;381:1107–1115.

Fiedler KA, Maeng M, Mehilli J, Schulz‐Schupke S, Byrne RA, Sibbing D, et al. Duration of triple therapy in patients requiring oral anticoagulation after drug‐eluting stent implantation: the ISAR‐TRIPLE trial. J Am Coll Cardiol. 2015;65:1619–1629.

Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med. 2016;375:2423–2434.

Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, et al. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med. 2017;377:1513–1524.

Lopes RD, Heizer G, Aronson R, Vora AN, Massaro T, Mehran R, et al. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med. 2019;380:1509–1524.

Vranckx P, Valgimigli M, Eckardt L, Tijssen J, Lewalter T, Gargiulo G, et al. Edoxaban‐based versus vitamin K antagonist‐based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST‐AF PCI): a randomised, open‐label, phase 3b trial. Lancet. 2019;394:1335–1343.

Hoshi T, Sato A, Hiraya D, Watabe H, Takeyasu N, Nogami A, et al. Short‐duration triple antithrombotic therapy for atrial fibrillation patients who require coronary stenting: results of the SAFE‐A study. EuroIntervention. 2020;16:e164–e172.

Smits PC, Frigoli E, Tijssen J, Juni P, Vranckx P, Ozaki Y, et al. Abbreviated antiplatelet therapy in patients at high bleeding risk with or without oral anticoagulant therapy after coronary stenting: an open‐label, randomized, controlled trial. Circulation. 2021;144:1196–1211.

Gargiulo G, Goette A, Tijssen J, Eckardt L, Lewalter T, Vranckx P, et al. Safety and efficacy outcomes of double vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta‐analysis of non‐vitamin K antagonist oral anticoagulant‐based randomized clinical trials. Eur Heart J. 2019;40:3757–3767.

Montalto C, Costa F, Leonardi S, Micari A, Oreglia JA, Vranckx P, et al. Dual antiplatelet therapy duration after percutaneous coronary intervention in patients with indication to oral anticoagulant therapy. A systematic review and meta‐analysis of randomized controlled trials. Eur Heart J Cardiovasc Pharmacother. 2023;9:220–230.

Matsumura‐Nakano Y, Shizuta S, Komasa A, Morimoto T, Masuda H, Shiomi H, et al. Open‐label randomized trial comparing Oral anticoagulation with and without single antiplatelet therapy in patients with atrial fibrillation and stable coronary artery disease beyond 1 year after coronary stent implantation. Circulation. 2019;139:604–616.

Yasuda S, Kaikita K, Akao M, Ako J, Matoba T, Nakamura M, et al. Antithrombotic therapy for atrial fibrillation with stable coronary disease. N Engl J Med. 2019;381:1103–1113.

Kaikita K, Yasuda S, Akao M, Ako J, Matoba T, Nakamura M, et al. Bleeding and subsequent cardiovascular events and death in atrial fibrillation with stable coronary artery disease: insights from the AFIRE trial. Circ Cardiovasc Interv. 2021;14: [eLocator: e010476].

Ando H, Yamaji K, Kohsaka S, Ishii H, Wada H, Yamada S, et al. Japanese Nationwide PCI (J‐PCI) registry annual report 2019: patient demographics and in‐hospital outcomes. Cardiovasc Interv Ther. 2022;37:243–247.

Ando T, Yamaji K, Kohsaka S, Fukutomi M, Onishi T, Inohara T, et al. Volume‐outcome relationship in complication‐related mortality after percutaneous coronary interventions: an analysis on the failure‐to‐rescue rate in the Japanese Nationwide registry. Cardiovasc Interv Ther. 2023;38:388–394.

Arai R, Oikawa Y, Nakazawa G, Matsuno S, Yajima J, Yamashita T. In vivo assessment of in‐stent restenosis after resolute zotarolimus‐eluting stent implantation: multimodality imaging with directional coronary atherectomy. Cardiovasc Interv Ther. 2023;38:244–245.

Fujii K, Kubo T, Otake H, Nakazawa G, Sonoda S, Hibi K, et al. Expert consensus statement for quantitative measurement and morphological assessment of optical coherence tomography: update 2022. Cardiovasc Interv Ther. 2022;37:248–254.

Fujii T, Amano K, Kasai S, Kawamura Y, Yoshimachi F, Ikari Y. Impact of renal function on adverse bleeding events associated with dual antiplatelet therapy in patients with acute coronary syndrome. Cardiovasc Interv Ther. 2024;39:28–33.

Fujimoto Y, Sakakura K, Fujita H. Complex and high‐risk intervention in indicated patients (CHIP) in contemporary clinical practice. Cardiovasc Interv Ther. 2023;38:269–274.

Hamana T, Kawamori H, Toba T, Nishimori M, Tanimura K, Kakizaki S, et al. Prediction of the debulking effect of rotational atherectomy using optical frequency domain imaging: a prospective study. Cardiovasc Interv Ther. 2023;38:316–326.

Higashino N, Ishihara T, Iida O, Tsujimura T, Hata Y, Toyoshima T, et al. Identification of post‐procedural optical coherence tomography findings associated with the 1‐year vascular response evaluated by coronary angioscopy. Cardiovasc Interv Ther. 2023;38:86–95.

Horak D, Bernat I, Jirous S, Slezak D, Rokyta R. Distal radial access and postprocedural ultrasound evaluation of proximal and distal radial artery. Cardiovasc Interv Ther. 2022;37:710–716.

Ikari Y, Saito S, Nakamura S, Shibata Y, Yamazaki S, Tanaka Y, et al. Device indication for calcified coronary lesions based on coronary imaging findings. Cardiovasc Interv Ther. 2023;38:163–165.

Kawamura A, Egami Y, Kawanami S, Sugae H, Ukita K, Nakamura H, et al. Preferable vascular healing of ultrathin strut biodegradable‐polymer sirolimus‐eluting stents in patients with acute coronary syndrome. Cardiovasc Interv Ther. 2022;37:681–690.

Koeda Y, Ishida M, Sasaki K, Kikuchi S, Yamaya S, Tsuji K, et al. Periprocedural and 30‐day outcomes of robotic‐assisted percutaneous coronary intervention used in the intravascular imaging guidance. Cardiovasc Interv Ther. 2023;38:39–48.

Koeda Y, Sasaki T, Numahata W, Ishida M, Morino Y. A case of robotic‐assisted percutaneous coronary intervention using a coronary intravascular lithotripsy catheter. Cardiovasc Interv Ther. 2023;38:429–430.

Koga M, Honda K, Higuma T, Akashi YJ. A case of myocardial infarction of the left circumflex artery accompanied by chronic total occlusion of the left anterior descending artery of the single coronary artery. Cardiovasc Interv Ther. 2023;38:427–428.

Koiwaya H, Nishihira K, Kadooka K, Kuriyama N, Shibata Y. Vascular healing in high‐bleeding‐risk patients at 3‐month after everolimus‐eluting stent versus biolimus A9‐coated stent implantation: insights from analysis of optical coherence tomography and coronary angioscopy. Cardiovasc Interv Ther. 2023;38:64–74.

Matsuhiro Y, Egami Y, Okamoto N, Kusuda M, Sakio T, Nohara H, et al. Early vascular healing of ultra‐thin strut polymer‐free sirolimus‐eluting stents in acute coronary syndrome: USUI‐ACS study. Cardiovasc Interv Ther. 2023;38:55–63.

Matsumoto T, Kitahara H, Yamazaki T, Hiraga T, Yamashita D, Sato T, et al. Very short‐term tissue coverage of the CD34 antibody‐covered sirolimus‐eluting stent: an optical coherence tomography study. Cardiovasc Interv Ther. 2023;38:381–387.

Muramatsu T, Kozuma K, Tanabe K, Morino Y, Ako J, Nakamura S, et al. Clinical expert consensus document on drug‐coated balloon for coronary artery disease from the Japanese Association of Cardiovascular Intervention and Therapeutics. Cardiovasc Interv Ther. 2023;38:166–176.

Nakamura M, Isawa T, Nakamura S, Ando K, Namiki A, Shibata Y, et al. One‐year safety and effectiveness of the agent paclitaxel‐coated balloon for the treatment of small vessel disease and in‐stent restenosis. Cardiovasc Interv Ther. 2024;39:47–56.

Nakanishi N, Kaikita K, Ishii M, Kuyama N, Tabata N, Ito M, et al. Japanese high bleeding risk criteria status predicts low thrombogenicity and bleeding events in patients undergoing percutaneous coronary intervention. Cardiovasc Interv Ther. 2023;38:299–308.

Natsuaki M, Sonoda S, Yoshioka G, Hongo H, Kaneko T, Kashiyama K, et al. Antiplatelet therapy after percutaneous coronary intervention: current status and future perspectives. Cardiovasc Interv Ther. 2022;37:255–263.

Nishi T, Sasahira Y, Kume T, Koto S, Uemura S. Rapid progression of calcified nodules with increased lipid core burden in the right coronary artery. Cardiovasc Interv Ther. 2023;38:248–250.

Numasawa Y, Matsumura A, Hashimoto R, Yokokura S, Haginiwa S, Kojima H. Pathological findings of honeycomb‐like structure resected by directional coronary atherectomy. Cardiovasc Interv Ther. 2023;38:121–123.

Ogawa T, Inoue Y, Aizawa T, Morimoto S, Ogawa K, Nagoshi T, et al. Investigation of the small‐balloon technique as a method for retrieving dislodged stents. Cardiovasc Interv Ther. 2023;38:309–315.

Okamura A, Nagai H, Tanaka K, Suzuki S, Watanabe H, Iwakura K. A case and video presentation using rotational ETOSS of intentional route tracing by angiography‐based 3D wiring in CTO‐PCI. Cardiovasc Interv Ther. 2022;37:743–744.

Okamura A, Nagai H, Tanaka K, Suzuki S, Watanabe H, Iwakura K. Possibility of AnteOwl IVUS‐based antegrade dissection and reentry using the tip detection method for CTO‐PCI. Cardiovasc Interv Ther. 2022;37:741–742.

Otake H, Ishida M, Nakano S, Higuchi Y, Hibi K, Kuriyama N, et al. Comparison of MECHANISM of early and late vascular responses following treatment of ST‐elevation acute myocardial infarction with two different everolimus‐eluting stents: a randomized controlled trial of biodegradable versus durable polymer stents. Cardiovasc Interv Ther. 2023;38:75–85.

Ozaki Y, Hara H, Onuma Y, Katagiri Y, Amano T, Kobayashi Y, et al. CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022. Cardiovasc Interv Ther. 2022;37:1–34.

Ozaki Y, Taniguchi M, Katayama Y, Satogami K, Ino Y, Tanaka A. Which is more useful for predicting no‐reflow phenomenon? Insights from optical coherence tomography and coronary computed tomography. Cardiovasc Interv Ther. 2023;38:246–247.

Saito Y, Kobayashi Y. Complete revascularization in acute myocardial infarction: a clinical review. Cardiovasc Interv Ther. 2023;38:177–186.

Saito Y, Kobayashi Y. Contemporary coronary drug‐eluting and coated stents: an updated mini‐review (2023). Cardiovasc Interv Ther. 2024;39:15–17.

Saito Y, Kobayashi Y, Fujii K, Sonoda S, Tsujita K, Hibi K, et al. CVIT 2023 clinical expert consensus document on intravascular ultrasound. Cardiovasc Interv Ther. 2024;39:1–14.

Saito Y, Tateishi K, Kanda M, Shiko Y, Kawasaki Y, Kobayashi Y, et al. Volume‐outcome relationships for extracorporeal membrane oxygenation in acute myocardial infarction. Cardiovasc Interv Ther. 2024;39:156–163.

Shishido K, Ando K, Ito Y, Takamisawa I, Yajima J, Kimura T, et al. Five‐year clinical outcomes of a 2.25 mm sirolimus‐eluting stent in Japanese patients with very small coronary artery disease: final results of the CENTURY JSV study. Cardiovasc Interv Ther. 2023;38:194–201.

Sonoda S, Hibi K, Okura H, Fujii K, Node K, Kobayashi Y, et al. Current clinical use of intravascular ultrasound imaging to guide percutaneous coronary interventions (update). Cardiovasc Interv Ther. 2023;38:1–7.

Taniguchi Y, Sakakura K, Jinnouchi H, Tsukui T, Fujita H. Rotational atherectomy to left circumflex ostial lesions: tips and tricks. Cardiovasc Interv Ther. 2023;38:367–374.

Tateishi K, De Gregorio J. Thrombectomy of right atrial thrombus for an elderly patient. Cardiovasc Interv Ther. 2023;38:260–261.

Tomoi Y, Kanenawa K, Otani A, Hirano T, Ando K. IMPELLA((R)) mechanical circulatory support delivery using a VIABAHN VBX‐covered stent. Cardiovasc Interv Ther. 2024;39:212–213.

Tsujimura T, Ishihara T, Takahashi K, Iida O, Hata Y, Toyoshima T, et al. Cutting balloons versus conventional balloons for treating patients with coronary artery disease presenting with moderate‐to‐severely calcified lesions: impact on post‐interventional minimum stent area. Cardiovasc Interv Ther. 2022;37:700–709.

Warisawa T, Cook CM, Kawase Y, Howard JP, Ahmad Y, Seligman H, et al. Physiology‐guided PCI versus CABG for left main coronary artery disease: insights from the DEFINE‐LM registry. Cardiovasc Interv Ther. 2023;38:287–298.

Yamaguchi T, Yamazaki T, Yoshida H, Matsumoto K, Yahiro R, Nakao K, et al. Tissue responses to everolimus‐eluting stents implanted in severely calcified lesions following atherectomy. Cardiovasc Interv Ther. 2024;39:34–44.

Yamazaki T, Nishi T, Saito Y, Tateishi K, Kato K, Kitahara H, et al. Discrepancy between plaque vulnerability and functional severity of angiographically intermediate coronary artery lesions. Cardiovasc Interv Ther. 2022;37:691–698.

Simonsson M, Wallentin L, Alfredsson J, Erlinge D, Hellstrom Angerud K, Hofmann R, et al. Temporal trends in bleeding events in acute myocardial infarction: insights from the SWEDEHEART registry. Eur Heart J. 2020;41:833–843.

Angiolillo DJ, Bhatt DL, Cannon CP, Eikelboom JW, Gibson CM, Goodman SG, et al. Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention: a north American perspective: 2021 update. Circulation. 2021;143:583–596.

Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2024;149:e1–e156.

Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomstrom‐Lundqvist C, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio‐Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42:373–498.

Collet JP, Thiele H, Barbato E, Barthelemy O, Bauersachs J, Bhatt DL, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST‐segment elevation. Eur Heart J. 2021;42:1289–1367.

Nakamura M, Kimura K, Kimura T, Ishihara M, Otsuka F, Kozuma K, et al. JCS 2020 guideline focused update on antithrombotic therapy in patients with coronary artery disease. Circ J. 2020;84:831–865.

Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, et al. Antithrombotic therapy for patients undergoing cardiac electrophysiological and interventional procedures: JACC state‐of‐the‐art review. J Am Coll Cardiol. 2024;83:82–108.

Koo BK, Kang J, Park KW, Rhee TM, Yang HM, Won KB, et al. Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention (HOST‐EXAM): an investigator‐initiated, prospective, randomised, open‐label, multicentre trial. Lancet. 2021;397:2487–2496.

Watanabe H, Morimoto T, Natsuaki M, Yamamoto K, Obayashi Y, Nishikawa R, et al. Clopidogrel vs aspirin monotherapy beyond 1 year after percutaneous coronary intervention. J Am Coll Cardiol. 2024;83:17–31.

Kogame N, Guimaraes PO, Modolo R, De Martino F, Tinoco J, Ribeiro EE, et al. Aspirin‐free prasugrel monotherapy following coronary artery stenting in patients with stable CAD: the ASET pilot study. JACC Cardiovasc Interv. 2020;13:2251–2262.

Muramatsu T, Masuda S, Kotoku N, Kozuma K, Kawashima H, Ishibashi Y, et al. Prasugrel monotherapy after percutaneous coronary intervention with biodegradable‐polymer platinum‐chromium everolimus eluting stent for Japanese patients with chronic coronary syndrome (ASET‐Japan). Circ J. 2023;87:857–865.

Natsuaki M, Watanabe H, Morimoto T, Yamamoto K, Obayashi Y, Nishikawa R, et al. An aspirin‐free versus dual antiplatelet strategy for coronary stenting: STOPDAPT‐3 randomized trial. Circulation. 2024;149:585–600.

Finocchiaro S, Capodanno D. Rethinking aspirin: ditching the daily “pill”ar of tradition. JACC Cardiovasc Interv. 2024;17:1246–1251.

Sotomi Y, Kozuma K, Kashiwabara K, Higuchi Y, Ando K, Morino Y, et al. Randomised controlled trial to investigate optimal antithrombotic therapy in patients with non‐valvular atrial fibrillation undergoing percutaneous coronary intervention: a study protocol of the OPTIMA‐AF trial. BMJ Open. 2021;11: [eLocator: e048354].

Asami M, OCEAN‐SHD Investigators. Computed tomography measurement for left atrial appendage closure. Cardiovasc Interv Ther. 2022;37:440–449.

Okada A, Kubo S, Chatani R, Mushiake K, Nishiura N, Ono S, et al. Feasibility of contrast‐free left atrial appendage closure with WATCHMAN FLX device for patients with chronic kidney disease. Cardiovasc Interv Ther. 2024;39:191–199.

Takeda K, Tsuboko Y, Iwasaki K. Latest outcomes of transcatheter left atrial appendage closure devices and direct oral anticoagulant therapy in patients with atrial fibrillation over the past 5 years: a systematic review and meta‐analysis. Cardiovasc Interv Ther. 2022;37:725–738.

Ueno H, Imamura T, Tanaka S, Ushijima R, Fukuda N, Kinugawa K. Initial report of percutaneous left atrial appendage closure in hemodialysis patients with atrial fibrillation and high risk of bleeding in Japan. Cardiovasc Interv Ther. 2023;38:338–347.