Dual and triple antithrombotic therapies: current patterns of practice and controversies

Area of Science:

• Cardiology
• Pharmacology
• Thrombosis Research

Background:

• Dual antiplatelet therapy (DAPT) is the standard for patients undergoing percutaneous coronary intervention (PCI).
• Triple antithrombotic therapy (acetylsalicylic acid, clopidogrel, and warfarin or NOAC) is recommended for PCI patients with atrial fibrillation requiring anticoagulation, despite increased bleeding risk.
• Existing evidence for triple therapy in this population is of low quality.

Purpose of the Study:

• To review current data on the efficacy and safety of various antithrombotic agent combinations.
• To compare different antithrombotic strategies in patients undergoing PCI, particularly those with atrial fibrillation.
• To evaluate newer antithrombotic regimens involving non-vitamin K antagonist oral anticoagulants (NOACs).

Main Methods:

• Literature review of randomized controlled trials and observational studies.
• Analysis of data on antithrombotic combinations including DAPT, triple therapy, and NOAC-based regimens.
• Synthesis of evidence regarding bleeding risk and thrombotic events.

Main Results:

• NOAC combined with a P2Y12 inhibitor appears safer and as effective as triple therapy with warfarin in acute coronary syndromes.
• Triple therapy significantly increases bleeding risk compared to DAPT.
• Recent trials on dabigatran and rivaroxaban support the use of NOACs in specific patient groups.

Conclusions:

• NOAC-based regimens, particularly NOAC plus P2Y12 inhibitor, offer a potentially safer alternative to traditional triple therapy.
• Careful consideration of bleeding risk versus thrombotic benefit is crucial when selecting antithrombotic strategies.
• Further research is needed to optimize antithrombotic management in complex PCI patients.