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Published on: February 26, 2013
Triple Therapy Versus Dual Antiplatelet Therapy for Patients with Atrial Fibrillation and Acute Coronary Syndromes: A
Aimee Fake1, Anil Ranchord2, Scott Harding2
1University of Otago, Wellington. 23A Mein St, Newtown, Wellington, New Zealand.
Insights
Triple therapy (TT) for acute coronary syndromes (ACS) and atrial fibrillation (AF) increases bleeding risk without clear ischemic benefits compared to dual antiplatelet therapy (DAPT). Evidence quality for current guidelines is poor.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Patients with acute coronary syndromes (ACS) and atrial fibrillation (AF) require both dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC).
- Current guidelines recommend triple therapy (TT), combining DAPT and OAC, for these patients.
- This review critically examines the comparative clinical outcomes of DAPT versus TT in this specific patient population.
Purpose of the Study:
- To compare the clinical outcomes, specifically ischemic and bleeding events, of dual antiplatelet therapy (DAPT) versus triple therapy (TT) in patients with acute coronary syndromes (ACS) and atrial fibrillation (AF).
- To evaluate the evidence supporting current guideline recommendations for managing ACS patients with AF.
Main Methods:
- A systematic literature search was conducted across major databases (Medline, EMBASE, etc.) for studies published between January 2000 and December 2016.
- Included studies focused exclusively on patients with AF and ACS, comparing DAPT and TT.
- Studies reporting ischemic and/or bleeding outcomes were analyzed; non-AF populations were excluded.
Main Results:
- Ten observational studies (8 retrospective) were included; none detailed treatment allocation specifics.
- Triple therapy (TT) was consistently associated with significantly increased bleeding risk compared to dual antiplatelet therapy (DAPT) (ORs 1.25–6.84).
- While one study suggested a stroke reduction with TT, others showed non-significant increases; no significant difference in composite ischemic endpoints was observed between DAPT and TT.
Conclusions:
- Triple therapy (TT) in ACS patients with AF appears to elevate bleeding risk without offering a clear advantage in reducing ischemic events.
- The existing evidence base supporting current guidelines for this patient cohort is of generally low quality.
- Further high-quality research is needed to clarify optimal antithrombotic strategies for ACS patients with AF.
Background:
Patients with acute coronary syndromes (ACS) and a history of atrial fibrillation (AF) have indications for both dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC). Triple therapy (TT), the combination of DAPT and OAC, is recommended in guidelines. We examined studies comparing clinical outcomes on DAPT versus TT for patients with AF and ACS.
Methods:
We searched Medline, Medline pending, EMBASE and Evidence-Based Medicine Reviews databases for studies published between January 2000 to December 2016 in AF patients with ACS that compared DAPT and TT that reported ischaemic and/or bleeding outcomes. Studies that were not purely an AF population were excluded.
Results:
Ten studies were included in the review, all of which were observational, 8 of which were retrospective. None of the studies detailed the specifics of treatment allocation. All but one were of AF patients with a mix of stable coronary disease and ACS patients. TT was associated with increased bleeding when compared to DAPT, with adjusted odds ratios ranging from 1.25 to 6.84. While the largest study reported a reduction in stroke associated with TT (odds ratio 0.67), two other studies reported non-significant increases in stroke with TT. Variable composite ischaemic endpoints were reported, none showing a statistical significant difference between DAPT and TT.
Conclusion:
In patients with ACS and AF, TT is likely to be associated with increased risk of bleeding, without a clear reduction in ischaemic endpoints. The quality of the evidence to support current guidelines for this patient group was generally poor.
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