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Role of triple antithrombotic therapy in patients with atrial fibrillation and coronary artery stents

Jeremy S Paikin, Shamir R Mehta and John W Eikelboom
Med J Aust 2010; 192 (9): 487-488.

Decisions regarding the use of triple therapy should take into account the balance between thromboembolism and bleeding risk in individual patients

The combined use of warfarin and dual antiplatelet therapy (aspirin plus clopidogrel) — so-called triple therapy — is a challenging management problem in patients with a coronary stent who also have an indication for oral anticoagulation. One of the most common clinical scenarios is a patient with atrial fibrillation (AF) who undergoes percutaneous coronary intervention with stenting. Guidelines for antithrombotic therapy recommend that patients with AF who are at high risk of stroke (ie, prior history of stroke or more than one of: age ≥ 75 years, hypertension, diabetes, and congestive cardiac failure) receive warfarin;1 and guidelines for percutaneous coronary intervention management recommend dual antiplatelet therapy in all stent patients to prevent stent thrombosis.2 Both warfarin and clopidogrel increase the risk of bleeding in patients treated with aspirin, and combining all three drugs can be expected to further increase bleeding risk. However, the efficacy and safety of triple therapy have not been evaluated in randomised controlled trials.

  • Jeremy S Paikin1
  • Shamir R Mehta2,1,3
  • John W Eikelboom1

  • 1 McMaster University, Hamilton, Ontario, Canada.
  • 2 Interventional Cardiology, Hamilton Health Sciences, Hamilton, Ontario, Canada.
  • 3 Population Health Research Institute, Hamilton, Ontario, Canada.

Correspondence: paikinjs@mcmaster.ca

Competing interests:

Shamir Mehta has been paid consultancy fees by Eli Lilly, AstraZeneca and sanofi-aventis, and has received a research grant from sanofi-aventis. John Eikelboom has been paid consultancy fees and/or received honoraria from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Corgenix, Daiichi Sankyo, Eisai, Eli Lilly, GlaxoSmithKline, Haemoscope, McNeil, and sanofi-aventis, and grants or in-kind support from Accumetrics, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Corgenix, Dade Behring, GlaxoSmithKline and sanofi-aventis. The views expressed in this article are solely ours, and are not influenced by any affiliated organisations.

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