open access

Vol 76, No 6 (2018)
Reviews
Published online: 2018-05-17
Submitted: 2018-05-14
Accepted: 2018-05-14
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Dual and triple antithrombotic therapies: current patterns of practice and controversies

Mark A. Crowther, John W. Eikelboom
DOI: 10.5603/KP.a2018.0112
·
Kardiol Pol 2018;76(6):937-944.

open access

Vol 76, No 6 (2018)
Reviews
Published online: 2018-05-17
Submitted: 2018-05-14
Accepted: 2018-05-14

Abstract

Dual antiplatelet therapy (DAPT) has been the cornerstone of antithrombotic management for patients undergoing percu­taneous coronary intervention (PCI). Despite low-quality evidence, triple antithrombotic therapy involving acetylsalicylic acid, clopidogrel, and warfarin or non-vitamin K antagonist oral anticoagulant (NOAC) has been recommended in patients with concomitant atrial fibrillation undergoing PCI, who require long-term oral anticoagulation, although such a strategy is associated with a substantially increased risk of bleeding compared with DAPT. NOAC combined with P2Y12 inhibitor alone appears to be safer and as effective as triple therapy with warfarin in patients with acute coronary syndromes based on the results of recent randomised trials on dabigatran and rivaroxaban. The present review summarises the current data on various combinations of antithrombotic agents in terms of their efficacy and safety.

Abstract

Dual antiplatelet therapy (DAPT) has been the cornerstone of antithrombotic management for patients undergoing percu­taneous coronary intervention (PCI). Despite low-quality evidence, triple antithrombotic therapy involving acetylsalicylic acid, clopidogrel, and warfarin or non-vitamin K antagonist oral anticoagulant (NOAC) has been recommended in patients with concomitant atrial fibrillation undergoing PCI, who require long-term oral anticoagulation, although such a strategy is associated with a substantially increased risk of bleeding compared with DAPT. NOAC combined with P2Y12 inhibitor alone appears to be safer and as effective as triple therapy with warfarin in patients with acute coronary syndromes based on the results of recent randomised trials on dabigatran and rivaroxaban. The present review summarises the current data on various combinations of antithrombotic agents in terms of their efficacy and safety.

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Keywords

dual antiplatelet therapy, atrial fibrillation, anticoagulation, bleeding; triple therapy

About this article
Title

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

Journal

Kardiologia Polska (Polish Heart Journal)

Issue

Vol 76, No 6 (2018)

Pages

937-944

Published online

2018-05-17

DOI

10.5603/KP.a2018.0112

Bibliographic record

Kardiol Pol 2018;76(6):937-944.

Keywords

dual antiplatelet therapy
atrial fibrillation
anticoagulation
bleeding
triple therapy

Authors

Mark A. Crowther
John W. Eikelboom

References (40)
  1. Rothberg M. Cost-effectiveness of clopidogrel plus aspirin versus aspirin alone. Ann Intern Med. 2005; 143(6): 464–465.
  2. Andreotti F, Testa L, Biondi-Zoccai GGL, et al. Aspirin plus warfarin compared to aspirin alone after acute coronary syndromes: an updated and comprehensive meta-analysis of 25,307 patients. Eur Heart J. 2006; 27(5): 519–526.
  3. Larson RJ, Fisher ES. Should aspirin be continued in patients started on warfarin? J Gen Intern Med. 2004; 19(8): 879–886.
  4. Dentali F, Douketis JD, Lim W, et al. Combined aspirin-oral anticoagulant therapy compared with oral anticoagulant therapy alone among patients at risk for cardiovascular disease: a meta-analysis of randomized trials. Arch Intern Med. 2007; 167(2): 117–124.
  5. Laffort P, Roudaut R, Roques X, et al. Early and long-term (one-year) effects of the association of aspirin and oral anticoagulant on thrombi and morbidity after replacement of the mitral valve with the St. Jude medical prosthesis: a clinical and transesophageal echocardiographic study. J Am Coll Cardiol. 2000; 35(3): 739–746.
  6. Massel DR, Little SH, Little SH, et al. Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database Syst Rev. 2003(4): CD003464.
  7. Iung B, Rodés-Cabau J. The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties. Eur Heart J. 2014; 35(42): 2942–2949.
  8. Falk V, Baumgartner H, Bax J, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017; 52(4): 616–664.
  9. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017; 70: 252–289.
  10. Iung B, Rodés-Cabau J. The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties. Eur Heart J. 2014; 35(42): 2942–2949.
  11. Massel D, Little S. Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database Syst Rev. 2013; 4: CD003464.
  12. Lip GY, Beevers DG. Interpretation of IST and CAST stroke trials. International Stroke Trial. Chinese Acute Stroke Trial. Lancet. 1997; 350(9075): 442–444.
  13. Sandercock PAG, Gibson LM, Liu M. Anticoagulants for preventing recurrence following presumed non-cardioembolic ischaemic stroke or transient ischaemic attack. Cochrane Database Syst Rev. 2009(2): CD000248.
  14. Anand S, Yusuf S, Xie C, et al. Warfarin Antiplatelet Vascular Evaluation Trial Investigators. Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. N Engl J Med. 2007; 357(3): 217–227.
  15. Perez-Gomez F, Alegria E, Berjon J, et al. Comparative effects of antiplatelet, anticoagulant, or combined therapy in patients with valvular and nonvalvular atrial fibrillation: a randomized multicenter study. J Am Coll Cardiol. 2004; 44: 1557–1566.
  16. Raju NC, Eikelboom JW, Hirsh J. Platelet ADP-receptor antagonists for cardiovascular disease: past, present and future. Nat Clin Pract Cardiovasc Med. 2008; 5(12): 766–780.
  17. Paikin JS, Eikelboom JW, Cairns JA, et al. New antithrombotic agents--insights from clinical trials. Nat Rev Cardiol. 2010; 7(9): 498–509.
  18. Eikelboom JW, Mehta SR, Anand SS, et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006; 114(8): 774–782.
  19. Hart RG, Pearce LA, Aguilar MI. Adjusted-dose warfarin versus aspirin for preventing stroke in patients with atrial fibrillation. Ann Intern Med. 2007; 147(8): 590–592.
  20. McNamara RL, Tamariz LJ, Segal JB, et al. Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Ann Intern Med. 2003; 139(12): 1018–1033.
  21. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007; 146(12): 857–867.
  22. Healey JS, Hart RG, Pogue J, et al. Risks and benefits of oral anticoagulation compared with clopidogrel plus aspirin in patients with atrial fibrillation according to stroke risk: the atrial fibrillation clopidogrel trial with irbesartan for prevention of vascular events (ACTIVE-W). Stroke. 2008; 39(5): 1482–1486.
  23. Connolly SJ, Pogue J, Hart RG, et al. ACTIVE Investigators. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009; 360(20): 2066–2078.
  24. Paikin JS, Wright DS, Crowther MA, et al. Triple antithrombotic therapy in patients with atrial fibrillation and coronary artery stents. Circulation. 2010; 121(18): 2067–2070.
  25. Sørensen R, Hansen ML, Abildstrom SZ, et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet. 2009; 374(9706): 1967–1974.
  26. Dewilde WJM, Oirbans T, Verheugt FWA, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013; 381(9872): 1107–1115.
  27. Gibson CM, Mehran R, Bode C, et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med. 2016; 375(25): 2423–2434.
  28. Mega JL, Braunwald E, Mohanavelu S, et al. Rivaroxaban versus placebo in patients with acute coronary syndromes (ATLAS ACS-TIMI 46): a randomised, double-blind, phase II trial. Lancet. 2009; 374(9683): 29–38.
  29. Mega JL, Braunwald E, Wiviott SD, et al. ATLAS ACS 2–TIMI 51 Investigators. Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med. 2012; 366(1): 9–19.
  30. Cannon CP, Bhatt DL, Oldgren J, et al. Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation. N Engl J Med. 2017; 377(16): 1513–1524.
  31. Faxon DP, Eikelboom JW, Berger PB, et al. Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting: a North-American perspective. Thromb Haemost. 2011; 106: 572–584.
  32. Angiolillo DJ, Goodman SG, Bhatt DL, et al. Antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a north american perspective - 2016 update. Circ Cardiovasc Interv. 2016; 9(11).
  33. Fiedler KA, Maeng M, Mehilli J, et al. Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After Drug-Eluting Stent Implantation: The ISAR-TRIPLE Trial. J Am Coll Cardiol. 2015; 65(16): 1619–1629.
  34. Kirchhof P, Benussi S, Kotecha D, et al. [2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS]. Kardiol Pol. 2016; 74: 1359–1469.
  35. Valgimigli M, Bueno H, Byrne RA, et al. [2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS]. Kardiol Pol. 2017; 75: 1217–1299.
  36. Macle L, Cairns J, Leblanc K, et al. 2016 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2016; 32(10): 1170–1185.
  37. Valgimigli M, Gagnor A, Calabró P, et al. MATRIX Investigators. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015; 385(9986): 2465–2476.
  38. Karrowni W, Vyas A, Giacomino B, et al. Radial versus femoral access for primary percutaneous interventions in ST-segment elevation myocardial infarction patients: a meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 2013; 6(8): 814–823.
  39. Baigent C, Blackwell L, Collins R, et al. Antithrombotic Trialists' (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009; 373(9678): 1849–1860.
  40. Levi M, de Peuter OR, Kamphuisen PW. Management strategies for optimal control of anticoagulation in patients with atrial fibrillation. Semin Thromb Hemost. 2009; 35(6): 560–567.

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