Safety of the cardiac triple therapy: The experience of the Quebec Heart Institute

Abstract

Contemporary treatment of acute coronary syndrome is based on the combination of acetylsalicylic acid (ASA) and clopidogrel. However, an increasing proportion of patients with cardiovascular disease also have an indication for anticoagulant therapy with warfarin. The combination of ASA, clopidogrel and warfarin, also called the cardiac triple therapy (CTT), is emerging in clinical practice, although little is known about its safety. To determine the risk of major and minor bleeding associated with the CTT compared with two other regimens using the combination of either ASA and clopidogrel or ASA and warfarin in patients with cardiovascular disease. A retrospective study was performed of all susceptible patients who may have received the CTT on discharge from the Quebec Heart Institute (Sainte-Foy, Quebec) between 2002 and 2005. The charts of patients treated with the CTT, ASA and clopidogrel, or ASA and warfarin were reviewed and patients were interviewed to document any bleeding episodes. A total of 183 patients were studied. Overall bleeding in the CTT group was 3% compared with 5% in the group receiving ASA and clopidogrel and 16% in the group receiving ASA and warfarin (P=0.03). Patients who experienced bleeding were older, had more hypertension and had been exposed to their drug regimens for a longer duration. There was no significant difference in major bleeding episodes. The CCT appears to be relatively safe compared with other regimens. Higher bleeding rates within the ASA-warfarin group emphasize the need to carefully educate and follow patients on combination therapy.