Triple antithrombotic therapy in patients with cardiovascular disease
- Nikolaus Sarafoff, MD
Nikolaus Sarafoff, MD
- Klinikum der Ludwig Maximilians Universität
- Munich, Germany
- David R Holmes, Jr, MD
David R Holmes, Jr, MD
- Professor of Medicine
- Mayo Clinic College of Medicine
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
Some patients with cardiovascular disease have indications for anticoagulant and dual antiplatelet therapy. It is estimated that between 5 and 10 percent of patients scheduled for coronary artery stenting, and who thus require dual antiplatelet therapy, are receiving oral anticoagulation (OAC), most often for atrial fibrillation [1,2]. The concomitant use of dual antiplatelet therapy using aspirin and a platelet P2Y12 receptor blocker and OAC is referred to as triple oral antithrombotic therapy (triple therapy). While the use of three antithrombotic agents reduces the rate of ischemic events, the risk of bleeding is significantly increased compared to one or two antithrombotic agents.
Formulating recommendations for the duration of antithrombotic therapy in patients with indications for triple therapy is a complicated process, in part because there is a broad range for the benefit (prevention of ischemic events) to risk (bleeding) ratio. Since the evidence base upon which recommendations can be made is weak, our recommendations represent consensus of our experts in some cases and a range of approaches in others.
This topic will provide the rationale for the use of triple therapy and will discuss its clinical use. Indications for either dual antiplatelet therapy (DAPT) or OAC in patients with cardiovascular disease are discussed extensively elsewhere:
●DAPT after stent implantation. (See "Antithrombotic therapy for elective percutaneous coronary intervention: General use".)
●DAPT after an acute coronary syndrome. (See "Antiplatelet agents in acute non-ST elevation acute coronary syndromes", section on 'Summary and recommendations' and "Antiplatelet agents in acute ST elevation myocardial infarction", section on 'Summary and recommendations'.)
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- OUR APPROACH
- Patients on long-term OAC
- Patients on DAPT after stent placement
- - Dosing
- - Gastroprotective therapy
- DURATION OF TRIPLE THERAPY
- Choice of stent
- MANAGEMENT AFTER TRIPLE THERAPY
- NEWER ANTITHROMBOTIC AGENTS
- Alternatives to clopidogrel
- Non-vitamin K antagonist oral anticoagulants
- PERIPROCEDURAL ISSUES
- MAJOR SOCIETY GUIDELINES
- NON-STENTED ACS PATIENTS REQUIRING OAC
- SUMMARY AND RECOMMENDATIONS