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Triple Antithrombotic Therapy - Always One Too Many?

bleeding risks. In this issue of the Journal, Sambola et al12 evaluate the efficacy and safety of TT in AF patients undergoing PCI compared with those of DAPT. They extracted data from a prospective multicenter registry that enrolled 585 AF patients undergoing PCI. The authors separately analyzed the results according to CHA2DS2-VASc score: CHA2DS2-VASc=1, 26.8% vs. CHA2DS2-VASc ≥2, 73.2%) In the 1-year followup of the patients, TT was not associated with less thromboembolic events, and the bleeding complication rate of TT was significantly higher compared with DAPT in the low thromboembolic risk group (CHA2DS2-VASc=1). In the higher thromboembolic risk group (CHA2DS2-VASc ≥2), TT was associated with a lower thromboembolic event rate compared with DAPT; however, the bleeding complication rate was higher. Multivariate analysis found that TT was an independent predictor for major bleeding complications; therefore, the authors concluded that TT involved a high risk for bleeding with no apparent benefit for AF patients with CHA2DS2VASc=1 undergoing PCI. The strength of this report lies in using the CHA2DS2-VASc score for risk stratification. Although previous studies (Table) have not investigated the individual risk of the patients, the omorbidity of atrial fibrillation (AF) and ischemic heart disease (IHD) is not uncommon. Approximately 5–10% of IHD patients are reported to be complicated by AF.1–3 Anticoagulation is recommended for patients with AF to prevent stroke and systemic thromboembolic events.4–6 Dual antiplatelet therapy (DAPT: aspirin plus P2Y12 inhibitor) has been the cornerstone of prevention of stent thrombosis in patients undergoing percutaneous coronary intervention (PCI). Therefore, AF patients who undergo PCI are often treated with triple therapy (TT: DAPT plus anticoagulation); however, the optimal combination therapy for such patients has not been fully determined.