Tools for Practice Outils pour la pratique

#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.

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

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 

Latest Tools for Practice
Derniers outils pour la pratique

#367 Oral Calcitonin Gene-related Peptide Antagonists: A painfully long name for the acute treatment of migraines

What are the risks and benefits of ubrogepant for the acute treatment of episodic migraines?
Read Lire 0.25 credits available Crédits disponibles

#366 Looking for Closure: Managing simple excisions or wounds efficiently

What are some options for efficiency in wound closure?
Read Lire 0.25 credits available Crédits disponibles

#365 Shrooms for Glooms: Evidence for psilocybin for depression

What are the benefits and harms of psilocybin for treatment-resistant/recurrent depression?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • 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.