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One of the most difficult clinical dilemmas is when to initiate “triple therapy” — the use of oral anticoagulation (OAC) with dual antiplatelet therapy (DAPT) in patients who have undergone percutaneous coronary intervention and have concurrent indications for OAC, such as atrial fibrillation or a mechanical heart valve. The need for triple therapy seems to be increasing as new risk scores (CHA2DS2-VASc) have expanded the number of atrial fibrillation patients recommended for OAC and DAPT now recommended for a least a year after percutaneous coronary intervention. But a new study suggests that more is perhaps not better. The study evaluated nearly 5000 patients age 65 or older with acute myocardial infarction and atrial fibrillation who underwent coronary stenting. Outcomes included major adverse cardiac events, including death, myocardial infarction, or stroke, while the primary outcome was bleeding. Triple therapy was used on 27.6% of patients, while the rest were on DAPT. Major adverse cardiac events occurred at about the same rate in both groups (hazard ratio [HR], 0.99; 95% confidence interval [CI], 0.86-1.16), while bleeding occurred much more frequently in the triple therapy group (HR 1.61; 95% CI, 1.31-1.97). Intracranial hemorrhage was twice as common in the triple therapy group (HR, 2.04; 95% CI, 1.25-3.34). The authors conclude that older AF patients who needed percutaneous coronary intervention had no better outcomes with triple therapy but had significantly higher bleeding rates (J Am Coll Cardiol 2015;66:616-627).
An accompanying editorial suggests it is not yet time to abandon triple therapy, but the optimal antiplatelet and anticoagulation therapy is not known. A recent study suggests that warfarin plus clopidogrel may lower major adverse cardiac events and bleeding rates. (Lancet 2013;381:1107-1115).
Complicating the issue is the role of the newer anticoagulants, which is still unknown. Although most evidence argues against triple therapy, more research is needed before we make a change (J Am Coll Cardiol 2015;66:628-630). Fortunately, ongoing studies may soon answer this difficult clinical dilemma.