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Triple Therapy: When, if Ever?

Nino Mihatov1, Eric A Secemsky1, Sammy Elmariah2

  • 1Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB 8-800, Boston, MA, 02114, USA.

Current Treatment Options in Cardiovascular Medicine
|July 4, 2018
PubMed

Insights

For patients needing both anticoagulation and stenting, shorter durations of triple therapy (dual antiplatelet therapy and oral anticoagulation) followed by dual therapy with oral anticoagulation and a P2Y12 inhibitor appear safe and effective.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Pharmacology

Background:

  • Over 9% of patients undergoing percutaneous coronary intervention (PCI) require long-term oral anticoagulation (OAC).
  • Optimal antithrombotic strategies for these high-risk patients remain unclear.
  • Dual antiplatelet therapy (DAPT) excels at preventing stent-related events, while OAC is superior for atrial fibrillation thromboembolism prevention.

Purpose of the Study:

  • To review current evidence on the safety and efficacy of dual therapy (OAC + P2Y12 inhibitor) versus triple therapy (DAPT + OAC) in stented patients requiring long-term anticoagulation.
  • To evaluate strategies involving shorter durations of triple therapy followed by dual therapy.

Main Methods:

  • Review of numerous studies comparing different antithrombotic regimens.
  • Analysis of data on stent-related events, thromboembolism, and bleeding risks.
  • Focus on recent findings regarding abbreviated triple therapy durations.

Main Results:

  • Triple therapy significantly increases bleeding risk (up to threefold) compared to warfarin monotherapy.
  • Shorter durations of triple therapy followed by dual therapy (OAC + P2Y12 inhibitor) have shown promising safety profiles.
  • Evidence supports the efficacy of OAC in preventing thromboembolism in atrial fibrillation patients.

Conclusions:

  • Dual therapy with OAC and a P2Y12 inhibitor offers a potentially safer alternative to prolonged triple therapy.
  • Optimizing antithrombotic strategies involves balancing the prevention of thrombotic events with minimizing bleeding complications.
  • Further research is needed to establish definitive guidelines for managing these complex patients.
Abstract

Keywords:
AnticoagulationCoronary artery diseasePercutaneous coronary interventionTriple therapy

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