Return of Oral Anticoagulation in Chronic Stable Coronary Disease.

Abstract

Antithrombotic therapy has been a cornerstone of secondary prevention for coronary artery disease (CAD) for the last 65 years. The first randomized trial with warfarin was carried out in New York and published in 1949. This landmark study was followed by many studies underscoring the benefit of warfarin. In the 1980s, aspirin emerged as a simple, lifesaving, and very cheap alternative and stayed there until today. In chronic CAD, the question emerged as to whether anticoagulant or antiplatelet agents are the better therapeutic. Several head-to-head comparisons of warfarin alone versus aspirin alone showed a large benefit of warfarin in reduction of myocardial infarction (MI) and stroke.1 Because of the complexity and bleeding risks with warfarin, few doctors returned to it, especially after the CURE trial (Clopidogrel in Unstable Angina to Prevent Recurrent Events) with aspirin plus clopidogrel was published. Thus, dual antiplatelet therapy (DAPT) became the standard of care after MI. Better results with DAPT after acute coronary syndromes (ACS) were obtained when clopidogrel was replaced with the stronger P2Y12 blockers prasugrel and ticagrelor. Another option was to prolong DAPT after MI beyond the guideline-mandated 12 months, when P2Y12 blockade traditionally is discontinued. Compared with aspirin monotherapy, DAPT prolongation is effective against ischemic events in several recent large randomized trials (DAPT2 and PEGASUS TIMI-54 [Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin–Thrombolysis in Myocardial Infarction 54]3) but is associated with increased bleeding without a significant mortality …