Triple Antithrombotic Therapy: Risky but Sometimes Necessary Tratamiento antitrombótico combinado triple: arriesgado pero a veces necesario

Antithrombotic therapy is the fundamental treatment for various cardiovascular conditions, e.g. ischemic heart disease, atrial fibrillation (AF), and stroke to prevent thrombotic complications and death. Dual antiplatelet inhibition with acetylsalicylic acid (ASA) and a P2Y12 inhibitor has proven most effective in patients with recent myocardial infarction (MI) or after percutaneous coronary intervention (PCI), whereas oral anticoagulation with vitamin K antagonist (VKA) or newer oral anticoagulants (NOACs: rivaroxaban, apixaban, or dabigatran) is most effective in AF. Long-term oral anticoagulation with VKA is also recommended in patients with mechanical heart valves. The safety and efficacy of different antithrombotic regimens have been assessed in randomized trials exploring treatments in patients with a unanimous indication for antithrombotic treatment, such as acute coronary syndrome (ACS) or AF. However, the need for antithrombotic protection can change over time due to temporal changes in the patient’s baseline risk, eg, after PCI, insertion of an artificial heart valve, occurrence of venous thromboembolism, or stroke. Approximately 6% to 8% of patients with ACS have an indication for oral anticoagulation, whereas 20% to 30% of patients with AF have co-existing ischemic heart disease. Consequently, the combination of dual-antiplatelet therapy and oral anticoagulation is frequently requested. Treatment with triple therapy, defined as treatment with ASA, a P2Y12 inhibitor and oral anticoagulation, can be indicated in some patients but usually for a limited period of time, the most typical clinical situation being a patient with a clear indication for oral anticoagulation experiencing an acute MI or treatment with PCI. The combined use of oral anticoagulation and antiplatelet therapy increases the risk of bleeding, whether considering triple therapy with VKA, ASA and clopidogrel or triple therapy with a NOAC. The knowledge and experience with NOACs in triple therapy is very sparse, and as co-existing ischemic heart disease is common in patients with AF, the bleeding risk related to triple therapy with NOACs is a major clinical question. Occurrence of bleeding is followed by an increased risk of thrombosis and death, thus triple antithrombotic therapy should be limited to the shortest possible time period, and should always be preceded by an individual assessment of bleeding risk.