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Triple therapy for atrial fibrillation and percutaneous coronary intervention: a contemporary review

Willem J M Dewilde1, Paul W A Janssen2, Freek W A Verheugt3

  • 1Department of Cardiology, Amphia Hospital, Breda, the Netherlands.

Journal of the American College of Cardiology
|September 20, 2014
PubMed

Insights

For patients on chronic oral anticoagulation undergoing stenting, triple therapy with aspirin and clopidogrel increases bleeding risk. Evidence suggests aspirin may not be necessary, challenging current guidelines for preventing thromboembolic events.

Area of Science:

  • Cardiology
  • Pharmacology

Background:

  • Chronic oral anticoagulation is standard for mechanical heart valves and atrial fibrillation (CHA2DS2-VASc score ≥1).
  • Percutaneous coronary intervention with stenting in these patients necessitates dual antiplatelet therapy alongside anticoagulation.
  • Historically, triple therapy (VKA, aspirin, clopidogrel) was recommended, but major bleeding is a significant concern.

Purpose of the Study:

  • To evaluate the necessity of aspirin in triple therapy for patients on oral anticoagulation undergoing stenting.
  • To determine the optimal balance between preventing thromboembolic events and minimizing bleeding risk in this patient population.

Main Methods:

  • Review of recent studies, including a prospective randomized trial, investigating triple therapy regimens.
  • Analysis of evidence regarding the efficacy and safety of adding aspirin to vitamin K antagonists and clopidogrel.

Main Results:

  • The evidence supporting the addition of aspirin to vitamin K antagonists and clopidogrel appears weakened.
  • Major bleeding is a recognized significant risk associated with traditional triple therapy.

Conclusions:

  • Re-evaluation of aspirin's role in triple therapy for anticoagulated patients undergoing stenting is warranted.
  • Finding an optimal antithrombotic strategy to prevent stent thrombosis and stroke without excessive bleeding remains a critical clinical challenge.

Keywords:
acenocoumarolclopidogreldual antiplatelet therapyoral anticoagulationphenprocoumonplatelet aggregation

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