Advertisement

Bleeding Risks with Triple Antithrombotic Therapy, Quantified

Summary and Comment |
September 26, 2012

Bleeding Risks with Triple Antithrombotic Therapy, Quantified

  1. Howard C. Herrmann, MD

Compared with an anticoagulant plus antiplatelet monotherapy, triple antithrombotic therapy increased bleeding risk by ≈40% without reducing risk for thrombotic events.

  1. Howard C. Herrmann, MD

Patients with both atrial fibrillation (AF) and acute coronary syndromes pose a difficult and frequent clinical conundrum: how to address the need for both anticoagulation and dual antiplatelet therapy without increasing bleeding risk. In this Danish study, investigators used national patient registries of all hospital admissions and prescriptions to study outcomes in 11,480 patients with AF who were hospitalized for myocardial infarction (MI) or percutaneous coronary intervention during a 9-year period.

At baseline, mean patient age was 76, and 61% were men. Patients received various combinations of aspirin, clopidogrel, and vitamin K antagonists (VKAs). At 1 year, the crude incidence rate of fatal or nonfatal bleeding per 100 person-years of therapy was 14.2 for triple therapy and ranged from 7.0 to 10.6 for dual therapy and from 6.6 to 7.0 for monotherapy. The bleeding rate with triple therapy was highest within 30 days after the index admission (22.6 per 100 person-years) but remained higher than with any other combination throughout the study period. In adjusted analyses, compared with dual therapy including VKA, triple therapy conferred a significantly increased risk for bleeding (hazard ratio, 1.41) but no significant benefit for the combined endpoint of cardiovascular death, MI, and ischemic stroke (HR, 1.15).

Comment

This large registry analysis provides unique quantitative data on the relative risks of combined antithrombotic therapies in patients with both atrial fibrillation and coronary artery disease — when each therapy is indicated, but no good studies of the combinations exist. Not surprisingly, the risk for major bleeding with triple antithrombotic therapy is high and sustained over time. New studies (some already initiated) that combine bleeding risk assessment with the efficacy of various dual combinations of agents in these patients are badly needed.

Citation(s):

Reader Comments (2)

Howard C. Herrmann

Dear Dr. Usdin: Thank you for your comment. The WOEST study has only been presented in preliminary form and has not yet been published in a peer-reviewed journal. It certainly adds to our understanding of this issue. However, it is a relatively small study (<300 pts per group) and is likely underpowered for many important endpoints (such as stent thrombosis).

Competing interests: None declared

Jean-Pierre USDIN

I do not precisely understand what Dr Herrmann means in the sentence "but no good studies of the combinations exist." One study on the combination Warfarin + Clopidogrel VS Warfarin+Aspirin+Clopidogrel was the subjet of the recent WEOST study, which showed definitly less bleeding in the case of patient suffering from AF + ACS treated with double therapy compared with triple treatment. may I have some explanation? thank you and sincerely dr Usdin Paris France.

Competing interests: None declared

Your Comment

(will not be published)

Filtered HTML

  • Allowed HTML tags: <a> <em> <strong> <cite> <blockquote> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Do you have any conflict of interest to disclose?
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
Image CAPTCHA
Enter the characters shown in the image.

Vertical Tabs

* Required

Reader comments are intended to encourage lively discussion of clinical topics with your peers in the medical community. We ask that you keep your remarks to a reasonable length, and we reserve the right to withhold publication of remarks that do not meet this standard.

PRIVACY: We will not use your email address, submitted for a comment, for any other purpose nor sell, rent, or share your e-mail address with any third parties. Please see our Privacy Policy.

Advertisement
Advertisement
Advertisement