Triple- or Dual-Therapy for Anticoagulation and Platelet Inhibition?
November 6, 2024
Written By Peter Liu
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Apixaban and a P2Y12 inhibitor is likely the safest antithrombotic regimen for patients with atrial fibrillation and recent acute coronary syndrome requiring both oral anticoagulation and platelet inhibition.
Synopsis
The AUGUSTUS trial assessed antithrombotic strategies in atrial fibrillation (AF) patients post-acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI). This 2 × 2 factorial randomized trial included 4,614 patients and compared apixaban versus warfarin and aspirin versus placebo, all alongside a P2Y12 inhibitor. Over 6 months, apixaban with placebo showed lower rates of death, major/clinically relevant nonmajor bleeding, and cardiovascular hospitalizations compared to other regimens, including those with warfarin and aspirin. No significant differences in ischemic events were observed across groups. The study supports using apixaban and a P2Y12 inhibitor without aspirin for optimal safety and efficacy in this population. [AI-generated]
DOAC/P2Y12 therapy generally favorable to triple-therapy; apixaban generally favorable to warfarin.
Patients with acute coronary syndrome (ACS) typically benefit from dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor like clopidogrel, ticagrelor, or prasugrel). However, when these patients also need systemic anticoagulation (e.g., for atrial fibrillation), triple therapy (aspirin, P2Y12 inhibitor, and anticoagulant) significantly raises bleeding risk without clear thrombotic benefits. This study supports findings from previous trials (WOEST, ISAR-TRIPLE, PIONEER AF-PCI, RE-DUAL PCI), reinforcing two principles. 1) Triple therapy increases bleeding risk without reducing thrombotic events, such as recurrent myocardial infarction, stroke, or cardiac death. 2) Direct oral anticoagulants (DOACs) present similar or lower bleeding risks compared to warfarin, with no difference in thrombotic outcomes. Thus, for patients requiring both P2Y12 inhibition and anticoagulation, dual therapy with a DOAC and a P2Y12 inhibitor is generally preferred. Apixaban, specifically, is supported by extensive evidence for a favorable bleeding risk profile. Clinicians should strongly consider DOAC/P2Y12 dual therapy over triple therapy or warfarin-containing regimens for ACS patients needing anticoagulation. Triple therapy should only be considered in rare cases where thrombotic risk is exceptionally high and bleeding risk is low.
Source
Antithrombotic Strategies in Atrial Fibrillation After ACS and/or PCI: A 4-Way Comparison From AUGUSTUS. J Am Coll Cardiol. 2024 Sep 3;84(10):875-885. doi: 10.1016/j.jacc.2024.06.022. PMID: 39197976.