Related Experiment Video
Updated: Apr 25, 2026
The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Atrial fibrillation and coronary artery disease: which antithrombotic treatment strategy?
Morten Lamberts1, Willem Dewilde, Morten Lock Hansen
1aDepartment of Cardiology, Gentofte University Hospital, Hellerup, Copenhagen, Denmark bDepartment of Cardiology, Amphia Hospital, Breda, the Netherlands.
Insights
For atrial fibrillation patients with coronary artery disease, dual therapy with oral anticoagulation plus clopidogrel may be a safer alternative to triple therapy. This approach reduces bleeding risk without increasing major cardiovascular events.
Area of Science:
- Cardiology
- Thrombosis Research
- Clinical Trial Analysis
Background:
- Optimal antithrombotic therapy for patients with atrial fibrillation and coronary artery disease remains controversial.
- Balancing the benefits of antithrombotic combinations against substantial bleeding risk is critical.
- Determining the appropriate duration, agents, and number of antithrombotic therapies is essential.
Purpose of the Study:
- To evaluate antithrombotic strategies in patients with atrial fibrillation and coronary artery disease.
- To assess the safety and efficacy of different antithrombotic regimens.
- To challenge current recommendations for triple therapy.
Main Methods:
- A randomized trial compared triple therapy (warfarin, clopidogrel, aspirin) with dual therapy (warfarin, clopidogrel) in patients undergoing percutaneous coronary intervention.
- A nationwide Danish registry study analyzed real-world data on antithrombotic use in similar patient populations.
- Outcomes assessed included bleeding events, major cardiovascular events, recurrent myocardial infarction, and death.
Main Results:
- The randomized trial showed a significantly reduced risk of any bleeding with dual therapy (warfarin + clopidogrel) compared to triple therapy, without increasing major cardiovascular events.
- Real-world data supported these findings, indicating no significant difference in recurrent myocardial infarction with dual therapy (warfarin + clopidogrel or warfarin + aspirin) versus triple therapy.
- However, the warfarin + aspirin regimen was associated with a significantly increased risk of death.
Conclusions:
- Dual therapy with oral anticoagulation and clopidogrel (without aspirin) is a viable alternative to triple therapy within 1 year post-myocardial infarction and/or percutaneous coronary intervention.
- This regimen offers a favorable benefit-risk profile regarding bleeding and cardiovascular events.
- Current consensus supports dual antiplatelet therapy plus oral anticoagulation, but oral anticoagulation plus clopidogrel presents a safer alternative.
Purpose Of Review:
The optimal antithrombotic therapy in patients with atrial fibrillation and coronary artery disease is controversial. The benefit of the combination of antithrombotic therapies remains debatable, and, as the bleeding risk is substantial, this calls for knowledge of the duration, and which and how many agents should be used.
Recent Findings:
The first randomized trial to challenge current recommendations of triple therapy (oral anticoagulation plus clopidogrel plus aspirin) examined patients on warfarin undergoing percutaneous coronary intervention with stent implantation. A reduced risk of any bleeding (hazard ratio 0.36) was found with combination of clopidogrel compared with triple therapy without increasing major cardiovascular events. In real-life patients, a nationwide Danish registry supported these findings, and, relative to triple therapy, no significant difference was found for recurrent myocardial infarction when adding only clopidogrel (hazard ratio 0.69) or aspirin (hazard ratio 0.96) to vitamin K antagonist. However, the latter regimen was associated with significantly increased risk of death.
Summary:
Within 1 year after myocardial infarction and/or percutaneous coronary intervention in patients with atrial fibrillation, current consensus papers endorse use of dual antiplatelet therapy on top of oral anticoagulation. A regimen consisting of oral anticoagulation and clopidogrel (without aspirin) could provide an alternative from a benefit and safety perspective.
Related Concept Videos
01:27Coronary Artery Disease V: Interprofessional Care
01:26Atherosclerosis III: Management
01:29Venous Thrombosis III: Interprofessional Care
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:26Angina IV: Management
01:18Anticoagulant Drugs: Vitamin K Antagonists and Direct Oral Anticoagulants
Warfarin, a prominent vitamin K antagonist family member, exerts its effect by inhibiting the enzyme VKORC1 (vitamin K epoxide reductase complex 1). By hindering this enzyme, warfarin...