Antithrombotic management in patients with atrial fibrillation, coronary artery disease, and intracranial hemorrhage: A case report and critical review of the literature

The coexistence of atrial fibrillation (AF), coronary artery disease (CAD) and the onset of intracranial haemorrhage (ICH) presents a complex therapeutic challenge, given the need to prescribe triple antithrombotic therapy to patients at high risk of bleeding and thrombosis. International guidelines advocate an individualized approach based on risk stratification. This case study presents the case of an octogenarian male with permanent atrial fibrillation (AF) and coronary artery disease (CAD), who underwent percutaneous revascularization and required sequential antithrombotic therapy. During his clinical course, he experienced an acute hemorrhagic cerebrovascular event, raising challenges regarding the timing of restarting appropriate antithrombotic therapy to provide the best efficacy and safety profile. Considering scientific evidence published up to 2024 and guidelines published by the ACC/AHA/ESC in 2024, we discuss sequential anticoagulation and antiplatelet restart strategies in patients with multiple cardiovascular comorbidities and central nervous system bleeding. Our case study highlights the importance of adopting a balanced therapeutic strategy tailored to each patient, incorporating thrombotic and hemorrhagic risk stratification tools to facilitate the most appropriate therapeutic decision and optimize efficacy and safety.