Trifecta or Triple Threat? The Challenge of Post-PCI Management in Patients Receiving Chronic Oral Anticoagulant Therapy

Abstract

We are fortunate to practice in an era of medicine which has many proven therapies. However, we are increasingly faced with coadministration of therapies whose combined effects have not been fully evaluated. Perhaps the most common and difficult of these scenarios is the use of dual antiplatelet therapy in patients who require chronic oral anticoagulation. Although each of these treatments has clear benefits, there is concern about bleeding risk when they are used together. Physicians are forced to choose between risking a thromboembolic or a bleeding complication. To best serve our patients, we must consider not only our initial reaction to do no harm, but go through the slower process of calculating the risk and severity of all possible adverse effects. However, for this process to succeed, we need robust data on which to base these calculations. This issue of the Canadian Journal of Cardiology (CJC) contains 2 articles which provide much-needed data. In the first, Ho and colleagues study the most common group of patients requiring chronic anticoagulation—individuals with atrial fibrillation. Their single-centre Canadian study included 602 patients with atrial fibrillation as their only indication for anticoagulation who underwent percutaneous coronary intervention (PCI) between 2008 and 2009. All were treated with dual antiplatelet therapy using aspirin and clopidogrel. The study was not randomized; however, physicians elected to treat 382 patients with triple therapy (ie, continued warfarin along with dual antiplatelet therapy), and 220 patients received dual antiplatelet therapy alone. Physicians clearly favoured triple therapy among patients with a higher risk of stroke, as patients receiving triple therapy were older (72.9 vs 70.5 years, P 0.039), were more likely to have suffered a previous stroke (14.4% vs 6.4%, P 0.01) and had a higher Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack CHADS2 score (2.6 vs 2.1; P 0.001). 6