Dual (Anticoagulant Plus Single Antiplatelet) vs Triple (Anticoagulant Plus Dual Antiplatelet) Antithrombotic Therapy - “Real World” Experience

Atrial fibrillation (AF) is a common arrhythmia that increases in prevalence with advancing age and in patients with coronary artery disease, revascularization, particularly with percutaneous coronary intervention (PCI), is also common. Both disease states have thrombosis as a core pathophysiologic process which requires treatment - low sheer stress thrombi in AF and intracoronary high sheer stress thrombi in PCI. For the 10-20% of patients who have both AF and undergo PCI, preventing thrombotic complications will require inhibition of both processes requiring simultaneous use of anticoagulation and antiplatelet therapy. There is a broad experience of combining oral anticoagulation therapy, used to prevent stroke and systemic embolization, in AF with dual antiplatelet therapy, used to prevent stent thrombosis and thrombotic coronary events. This “triple antithrombotic therapy” (TT) has been evaluated through many observation studies, both small and large. TT has more frequently been associated with a significant increase in bleeding events with non-significant reduction in thrombotic events. Current guidelines recommend shorter duration of TT, especially in patients with high risk of bleeding.