In patients with non-valvular
atrial fibrillation (NVAF) and history of
transient ischemic attack (TIA) or
stroke, the rate of vascular events is higher in comparison to patients without history of
stroke or TIA. A meta-analysis of direct oral
anticoagulants (DOACs) studies, including only patients with history of
stroke or TIA, report a significant reduction of 15 % in the rates of composite of
stroke and systemic
embolism in patients treated with DOACs, compared to those treated with
warfarin. Furthermore, a reduction of 14 % for major
bleeding, as well as a 56 % reduction for
hemorrhagic stroke over a median follow-up of 1.8-2.0 years is reported. The combination of DOACs and
antiplatelet agents carries the potential of additive benefits in patients with NVAF and other
vascular diseases. However, the rate of major
bleeding is higher among patients who receive concomitantly
antiplatelet agents, compared to those taking only a single drug category. The risk of major
bleeding seems to be higher among patients receiving dual
antiplatelet agents, compared to those receiving a single
antiplatelet drug. When NVAF is associated with an
acute coronary syndrome requiring dual antiplatelet
therapy (e.g. coronary angioplasty and stenting), DOACs plus this
therapy should be considered. However, this
therapy has to be administered for the shortest possible time, according to the patient's haemorrhagic and thrombotic risks, and
stent type. When NVAF is associated with
carotid stenosis, a single antiplatelet
therapy should be considered. Regarding carotid revascularization, it seems preferable to treat these patients with
endarterectomy, so to avoid dual antiplatelet
therapy, which is generally administered after stenting.