Abstract
The number of patients with atrial fibrillation (AF) is increasing due to the aging of the population. In addition, the number of patients with AF and indications for oral anticoagulation (OAC) for the prevention of stroke, who need dual antiplatelet treatment (DAPT) with acetylsalicylic acid (ASA) plus aP2Y12 inhibitor because of an acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI) is also increasing. In the past these patients received atriple therapy (TT) for 3-12months. This TT has never been studied for efficacy; however, the rate of bleeding complications in comparison to a simple OAC or DAPT is significantly higher. Registries and smaller trials showed that DAPT with an OAC plus aplatelet inhibitor may be sufficient to prevent stroke and stent thromboses/myocardial infarctions. These questions were investigated in various prospective and randomized studies involving all four non-vitaminK oral anticoagulants (NOAC) approved for stroke prevention in AF. The NOACs were tested against vitaminK antagonists (VKA) involving single antiplatelet therapy without using DAPT. The trials with rivaroxaban (PIONEER AF-PCI) and dabigatran (RE-DUAL PCI) have already been published but the investigations involving apixaban (AUGUSTUS) and edoxaban (ENTRUST-AF PCI) are still ongoing. The current status is that aNOAC plus asingle antiplatelet agent, mostly clopidogrel, is superior to TT with VKA with respect to bleeding complications without any obvious disadvantage due to increases in stroke cases or cardiac ischemia. The international guidelines already permit treatment without TT in cases where the bleeding risk is prevalent. In this situation it is recommended to prescribe aNOAC plus asingle antiplatelet therapy. Thus, TT no longer seems to be indicated for most patients with AF and after ACS or PCI.
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