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#226 Two’s Company, Three’s a Crowd: Dual versus triple therapy post-PCI

Should patients already on oral anticoagulation who undergo percutaneous coronary intervention (PCI), receive one antiplatelet + one anticoagulant (dual therapy) or two antiplatelets + one anticoagulant (triple therapy)?

Compared to triple therapy, dual therapy lowers bleeding risk (one fewer bleed for every 6-11 patients) and may decrease cardiovascular events or mortality. Most patients on OAC having PCI should be offered dual therapy.

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Three high-quality, randomized controlled trials (RCTs) of mostly atrial fibrillation patients (~70 years old) who received PCI. Bleeding definitions varied, clinically relevant bleeds (resulting in at least a medical visit or intervention) reported below. Results statistically significant unless indicated: 
  • WOEST:1 Smallest trial (573 patients), but directly answers question. Clopidogrel + oral anticoagulant (dual) versus clopidogrel + ASA + oral anticoagulant (triple) for one month to one year (at physician’s discretion). At one year: 
    • Bleeding: 
      • Dual 14.0%, triple 31.3%; Number Needed to Treat (NNT)=6. 
    • Composite of death, myocardial infarction (MI), stroke, revascularization, or stent thrombosis:  
      • Dual 11.1%, triple 17.6%; NNT=16. 
    • Stent thrombosis, MI, target-vessel revascularization, and stroke (hemorrhagic or ischemic) 
      • None statistically different. 
    • All-cause mortality:  
      • Dual 2.5%, triple 6.3%; NNT=27. 
  • RE-DUAL:2 Largest trial (2,725 patients). P2Y12 inhibitor (mostly clopidogrel+ dabigatran (110 mg or 150 mg) (dual) versus P2Y12 inhibitor + ASA + warfarin (triple)Patients over age 70-80 received dabigatran 110 mg 
    • Results (dual therapy groups combinedat 14 months: 
      • Bleeding:  
        • Dual 17.5%, triple 26.9%, statistically significant; NNT=11. 
      • No difference in other clinically important cardiovascular outcomes.  
  • PIONEER:3 2,124 patientsThree arms (including ultra-low dose rivaroxaban arm). Focusing on P2Y12 inhibitor (mostly clopidogrel) + rivaroxaban 15 mg (dual) versus P2Y12 inhibitor + ASA + warfarin (triple). 
    • Results (12 months): 
      • Bleeding:  
        • Dual 16.8%, triple 26.7%; NNT=11. 
      • Composite of death, MI, stroke, revascularization, or stent thrombosis: No difference.   
  • Systematic reviews report similar conclusions but included cohort studies and irrelevant RCTs.4,5 
  • Approximately 20% of patients with atrial fibrillation have coronary artery disease.6,7 
  • Canadian guidelines recommend dual therapy (oral anticoagulation + clopidogrel) for up to one year for patients with atrial fibrillation 65 years and CHADS2 ≥1 undergoing PCI.8 

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  • Caitlin R Finley BHSc MSc
  • Michael R Kolber MD CCFP MSc

1. Dewilde WJM, Oirbans T, Verheugt FWA, et al. Lancet. 2013; 381:1107-15.

2. Cannon CP, Bhatt DL, Oldgren MPHJ, et al. N Engl J Med. 2017; 377:1513-24.

3. Gibson CM, Mehran R, Bode C, et al. N Engl J Med. 2016; 375:2423-34.

4. Golwala HB, Cannon CP, Steg PG, et al. Eur Heart J. 2018; 39:1726-35.

5. Gong X, Tang S, Li J, et al. PLoS ONE. 2017; 12:e0186449.

6. Connolly SJ, Ezekowitz MD, Yusuf S, et al. NEJM. 2009; 361:1139-51.

7. Camm AJ, Accetta G, Ambrosio G, et al. Heart. 2017; 103:307-14.

8. Mehta SR, Bainey KR, Cantor WJ, et al. Can J Cardiol. 2018; 34:214-33.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.