In all three studies, roughly one-third of patients presented with ACS. There was no interaction between the duration of triple therapy and clinical presentation (ACS vs. no ACS), which may reflect a real lack of increased coronary ischaemic risk in these patients or a lack of power to detect clinically meaningful differences in coronary ischaemic outcomes if these patients undergo shorter duration of DAPT regimen (i.e. 1 month195 or immediate discontinuation of aspirin after PCI191,193). The rate of bleeding events peaked within the first 30 days of initiation of triple therapy and was twice as high when compared with the rate of acute coronary events including recurrent MI and stent thrombosis. These observations are consistent with the nationwide Danish registry of AF all-comers with MI, where the 90-day bleeding risk was increased on triple therapy compared with OAC plus a single antiplatelet agent (HR 1.47, 95% CI 1.04–2.08), with a consistent trend at 360 days (HR 1.36, 95% CI 0.95–1.95), without differences in ischaemic events (HR 1.15, 95% CI 0.95–1.40).196 The same registry suggests that warfarin plus clopidogrel resulted in a non-significant reduction in major bleeds (HR 0.78, 95% CI 0.55–1.12) compared with triple therapy, with a non-significant reduction in MI or coronary death (HR 0.69, 95% CI 0.55–1.12).197 For these reasons, duration of triple therapy should be minimized depending on bleeding and ischaemic risks (Figure 7; Tables 5 and 6).
High-risk features of stent-driven recurrent ischaemic events
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High-risk features of stent-driven recurrent ischaemic events
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Unfavourable patient profile for a combination of oral anticoagulant and antiplatelet therapy
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Unfavourable patient profile for a combination of oral anticoagulant and antiplatelet therapy
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Dual antiplatelet therapy duration in patients with indication for oral anticoagulation
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ACS = acute coronary syndrome; AF = atrial fibrillation; b.i.d. = bis in die; CrCl = creatinine clearance; INR = international normalized ratio; NOAC = non-vitamin K oral anticoagulant; OAC = oral anticoagulant; q.d. = quaque die; VKA = vitamin K antagonist.
Class of recommendation.
Level of evidence.
Apixaban 5 mg b.i.d or apixaban 2.5 mg b.i.d. if at least two of the following: age ≥80 years, body weight ≤60 kg or serum creatinine level ≥1.5 mg/dL (133 μmol/L); dabigatran 110 mg b.i.d.; edoxaban 60 mg q.d. or edoxaban 30 mg q.d. if any of the following: CrCl of 30–50 mL/min, body weight ≤60 kg, concomitant use of verapamil, quinidine, or dronedarone; rivaroxaban 20 mg q.d. or rivaroxaban 15 mg q.d. if CrCl 30–49 mL/min.
Dual antiplatelet therapy duration in patients with indication for oral anticoagulation
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ACS = acute coronary syndrome; AF = atrial fibrillation; b.i.d. = bis in die; CrCl = creatinine clearance; INR = international normalized ratio; NOAC = non-vitamin K oral anticoagulant; OAC = oral anticoagulant; q.d. = quaque die; VKA = vitamin K antagonist.
Class of recommendation.
Level of evidence.
Apixaban 5 mg b.i.d or apixaban 2.5 mg b.i.d. if at least two of the following: age ≥80 years, body weight ≤60 kg or serum creatinine level ≥1.5 mg/dL (133 μmol/L); dabigatran 110 mg b.i.d.; edoxaban 60 mg q.d. or edoxaban 30 mg q.d. if any of the following: CrCl of 30–50 mL/min, body weight ≤60 kg, concomitant use of verapamil, quinidine, or dronedarone; rivaroxaban 20 mg q.d. or rivaroxaban 15 mg q.d. if CrCl 30–49 mL/min.
