O PIONEERs! The Beginning of the End of Full-Dose Triple Therapy with Warfarin?

Abstract

Article, see p 323 One of the most common conundrums in all of cardiovascular medicine pertains to the care of patients with atrial fibrillation who need percutaneous coronary intervention. Both dual antiplatelet therapy (DAPT) and oral anticoagulant therapy would seem to be necessary to reduce risks of stent thrombosis and thromboembolism, respectively.1 However, with intensification of the antithrombotic regimen, there is an inevitable tradeoff with more bleeding.2 Two modest-sized randomized trials, WOEST (What Is the Optimal Antiplatelet and Anticoagulant Therapy in Patients With Oral Anticoagulation and Coronary Stenting) and ISAR-TRIPLE (Intracoronary Stenting and Antithrombotic Regimen: Testing of a Six-Week Versus a Six-Month Clopidogrel Treatment Regimen in Patients With Concomitant Aspirin and Oral Anticoagulant Therapy Following Drug-Eluting Stenting), have shown that double therapy (single antiplatelet therapy plus full-dose vitamin K antagonists) appeared to provide similar efficacy and reduced bleeding compared with triple therapy (DAPT plus full-dose vitamin K antagonists).3,4 Curiously, even a signal of less ischemic/thrombotic complications occurred with double therapy, although these 2 trials were clearly not powered for efficacy end points. It remained possible, however, that excess bleeding with triple therapy overwhelmed any potential gain in efficacy.5 Furthermore, the role, if any, of the novel oral anticoagulants (NOACs), instead of vitamin K antagonists such as warfarin, remained poorly characterized. In this issue of Circulation , Gibson et al6 have published the key data from the PIONEER AF-PCI (An Open-Label, Randomized, Controlled, Multicenter Study Exploring Two Treatment Strategies of Rivaroxaban and a Dose-Adjusted Oral Vitamin K Antagonist Treatment Strategy in Subjects With Atrial Fibrillation Who Undergo Percutaneous Coronary Intervention) trial. A total of 2124 stented patients with atrial fibrillation were randomized to 1 of 3 groups: reduced-dose rivaroxaban 15 mg daily plus a P2Y12 for 12 months (Group 1); rivaroxaban 2.5 mg …