After PCI, Two Anticoagulants May Be As Effective As Three Interview with:

Nayan Agarwal MD Intervention Cardiology Fellow, University of Florida, Gainesville, FL

Dr. Agarwal

Nayan Agarwal MD
Intervention Cardiology Fellow,
University of Florida,
Gainesville, FL What is the background for this study?

Response: Long term anticoagulation is indicated in patients with mechanical heart valves, prior thromboembolic events, atrial fibrillation etc, to prevent recurrent thrombo-embolic episodes. About 20-30% of these patients also have concomitant ischemic heart disease requiring percutaneous coronary intervention (PCI).

Post PCI, patients require treatment with dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) to prevent stent thrombosis. Thus, these patients may end up needing triple antithrombotic therapy with oral anticoagulant (OAC) and DAPT, which increases the bleeding risk.

Both American College of Cardiology(ACC) and European Society of Cardiology (ESC), currently recommend triple therapy in these patients. Recently new evidence has emerged that such patients can be managed with dual therapy of a single antiplatelet (SAPT) and OAC. Hence, we decided to do a systematic review of these studies to evaluate safety and efficacy of dual therapy of SAPT and OAC against triple therapy of DAPT and OAC. What are the main findings?

Response: Nine observational studies and 2 randomized studies with a total of 7,276 patients met our selection criteria. At a mean follow up of 10.8 months risk of major bleeding was 54% higher in triple therapy cohort compared to dual therapy cohort (6.6% versus 3.8%, RR 1.54, CI- 1.2-1.98, p<0.01) without any difference in all-cause mortality (RR 0.98, 95% CI 0.68-1.43, P=0.93), major adverse cardiac events (RR 1.03, 95% CI 0.8-1.32, P=0.83), thromboembolic events (RR 1.02, 95% CI 0.49-2.10, P=0.96), myocardial infarction (RR 0.85, 95% CI 0.67-1.09, P=0.21), stent thrombosis (RR 0.77, 95% CI 0.46-1.3, P=0.33) and target vessel revascularization (RR 0.87, 95% CI 0.66-1.15, P=0.33). What should readers take away from your report?

Response: In patients with an indication for long term anticoagulation needing PCI the dual therapy with SAPT and OAC is equally effective to triple therapy with OAC and DAPT in preventing coronary ischemia, stent thrombosis, mortality and thromboembolic events and is also safer, since it reduces the incidence of major bleeding events. We should strongly consider treating these patients with dual therapy instead of triple therapy. What recommendations do you have for future research as a result of this study?

Response: In our current analysis 10/11 studies used coumadin as the OAC and only one used new oral anticoagulant (NOAC) as the OAC therapy. With the growing use of NOAC, we need more research in future to understand the safety of NOACS in these patients. We also need more research to assess the safety of newer P2Y12 inhibitor (ticagrelor, prasugrel) when combined with OAC.

No relevant financial disclosures. Thank you for your contribution to the community.


Agarwal N, Jain A, Mahmoud AN, Bishnoi R, Golwala H, Karimi A, Mojadidi MK, Garg J, Gupta T, Patel NK, Wayangankar S, Anderson RD, Safety and Efficacy of Dual versus Triple Antithrombotic Therapy in Patients Undergoing Percutaneous Coronary Intervention. The American Journal of Medicine(2017), doi: 10.1016/j.amjmed.2017.03.057

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on May 5, 2017 by Marie Benz MD FAAD