A triple therapy approach of warfarin, clopidogrel and aspirin substantially reduces the risk of ischemic stroke and stent thrombosis compared to dual antiplatelet therapy (DAPT), according to a meta-analysis of patients with atrial fibrillation (AFib) undergoing coronary stenting. However, the three-medication strategy is associated with a higher bleeding risk.
A group of Chinese researchers led by Liyao Liu studied 11,697 AFib patients from 14 studies who required percutaneous coronary intervention (PCI). Triple therapy (TT) is recommended in European guidelines for people in this situation, but the authors pointed out some clinicians are unwilling to prescribe so many anticoagulants because they fear it may increase bleeding risk.
In fact, a recent meta-analysis in the European Heart Journal found that AFib patients who received DAPT after PCI had a 47 percent reduction in bleeding events compared to those who took three blood thinners. Notably, the incidence of major adverse cardiac events (MACE) was similar between groups.
Likewise, in this PLOS One analysis, the rates of MACE, myocardial infarction and morality were similar between groups. But Liu et al. also observed TT was associated with a 26 percent reduced risk of ischemic stroke and a 40 percent reduced risk of stent thrombosis compared with DAPT.
Major bleeding was reported in 13.1 percent of patients on TT and 9.9 percent of patients on DAPT—a 55 percent relative reduction for the simpler approach of clopidogrel plus aspirin.
“TT did not increase the risk of MACE and all-cause mortality irrespective of the increased major bleeding risk,” the researchers wrote. “These were in contrast with (a) previous study which reported that major bleeding (was) the most important cause of mortality among patients who underwent coronary stenting requiring oral anticoagulation therapy. In terms of the incidence of major bleeding in our analysis, it was difficult to compare the absolute rate among studies owing to the different bleeding definitions, follow-up duration and comorbidities in each study.”
Liu and colleagues also acknowledged significant heterogeneity was present in their bleeding calculation, likely to due to a large proportion of included studies containing Asian subjects. In addition, they couldn’t weigh the role of the stent type or the severity of clinical presentation, which could have affected long-term outcomes.
Emerging non-vitamin K antagonist oral anticoagulants should also be evaluated as a replacement to warfarin in TT, but long-term research for them is still ongoing, the authors noted.
“Our study revealed that compared with DAPT, TT reduced the risk of ischemic stroke and stent thrombosis with an acceptable risk of increasing major bleeding in AF patients undergoing coronary stenting,” they wrote. “TT was considered as a valid alternative in those patients, which was consistent with current guidelines. However, it is crucial that further prospective randomized trials are needed to ensure the reliability of these data and find the optimal therapeutic strategy in this setting of patients.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.