The necessity of personalized medicine in patients with coronary heart disease and atrial fibrillation in real clinical practice: a clinical case

The use of antithrombotic drugs is a fundamental principle in the treatment of patients with coronary artery disease and atrial fibrillation. However, when prescribing combined treatment regimens, there is a natural increase in the risk of hemorrhagic complications, both clinically significant, life-threatening, and minor annoying ones that reduce patient compliance, which steadily leads to thromboembolic complications. The interindividual variability in the efficacy and safety of clopidogrel and direct oral anticoagulants may be due, among other factors, to the genetic characteristics of the patient. The results of modern research are ambiguous and dictate further study of this issue. The article presents a clinical case of a 61-year-old man with a combination of coronary artery disease and atrial fibrillation, who was prescribed clopidogrel, acetylsalicylic acid and rivaroxaban after stenting. Against the background of the development of extensive hematomas up to 15 cm in diameter and nosebleeds, treatment was replaced first with double antithrombotic therapy (acetylsalicylic acid was discontinued), and then with clopidogrel and apixaban. According to the results of an additional pharmacogenetic study, it was revealed that the patient was a carrier of CYP2C19*17/*17 (the CYP2C19 ultra-rapid metabolizer genotype), CYP3A5*3/*3, of the TT genotype according to the polymorphic variant rs2032582 of the ABCB1 gene. The bleeding was assessed retrospectively and then over the follow-up period (16 weeks). Understanding the genetic factors influencing the therapeutic response may allow doctors to optimize commonly accepted treatment regimens and minimize unwanted drug reactions.