The AFIRE trial demonstrated that, in patients with stable CAD and AF, rivaroxaban therapy alone compared to rivaroxaban plus an anti-platelet agent leads to fewer adverse bleeding events and is non-inferior with respect to hard clinical outcomes. The AUGUSTUS trial showed that, in patients with atrial fibrillation presenting with ACS or undergoing PCI, apixaban is safer than warfarin, adding aspirin on top of an anticoagulant and a P2Y12 inhibitor increases bleeding, and interestingly treating these patients with an oral anticoagulant and a single anti-platelet agent did not led to increased thrombotic events.

How much are these trials (and others which I may be omitting) changing practice? Are we able to confidently treat the patient with stable CAD and AF with an oral anticoagulant alone? Should we be treating the patient with AF and recent ACS/PCI with an anti-Xa agent and a P2Y12 inhibitor only? Are there any patients with CAD and AF who would benefit from triple therapy with an oral anticoagulant and dual anti-platelet therapy? If so, for how long do those patient need triple therapy?