From the Guidelines
For elderly patients with atrial fibrillation and recent NSTEMI who underwent PCI, triple antithrombotic therapy should be limited to 1 month, followed by dual therapy, as this approach has been shown to minimize bleeding complications while maintaining efficacy in preventing thromboembolic events 1.
Recommended Therapy Duration and Components
The recommended initial triple therapy consists of a direct oral anticoagulant (preferably apixaban 5mg twice daily or rivaroxaban 15mg daily), aspirin 81mg daily, and clopidogrel 75mg daily.
- After 1 month, discontinue aspirin and continue the DOAC plus clopidogrel for up to 12 months.
- For patients at very high bleeding risk, consider shortening triple therapy to just 1 week.
- After 12 months, transition to DOAC monotherapy indefinitely.
Rationale and Evidence
This approach is supported by recent studies, including the RE-DUAL PCI trial, which demonstrated that dual antithrombotic therapy with dabigatran and a P2Y12 inhibitor was noninferior to triple therapy with warfarin, a P2Y12 inhibitor, and aspirin in terms of thromboembolic events, with a significantly lower risk of bleeding 1.
Monitoring and Adjustments
Dose adjustments may be needed based on renal function, weight, and drug interactions.
- Regular monitoring of renal function, complete blood count, and bleeding signs is essential.
- Proton pump inhibitors (like pantoprazole 40mg daily) should be prescribed concurrently to reduce gastrointestinal bleeding risk during antithrombotic therapy.
Considerations for High Bleeding Risk
For patients at high ischemic/thrombotic and low bleeding risks, it may be reasonable to extend aspirin therapy up to 1 month after PCI, but this should be done with caution and careful consideration of the individual patient's risk profile 1.
From the Research
Recommended Duration of Triple Therapy
The recommended duration of triple therapy in elderly patients with a history of atrial fibrillation (AFib) and non-ST-elevation myocardial infarction (NSTEMI) after recent percutaneous coronary intervention (PCI) is as follows:
- Triple antithrombotic therapy (OAC + P2Y12 inhibitor + aspirin) for 7 days or less, followed by double antithrombotic therapy (OAC + P2Y12 inhibitor) for 6 to 12 months 2
- This approach is based on the results of five major randomized clinical trials that compared double antithrombotic therapy with OAC and a P2Y12 inhibitor versus triple therapy in patients with AF who underwent PCI or had an ACS event
Rationale for Recommended Duration
The rationale for this recommended duration is to balance the risk of bleeding events and ischemic or thrombotic events:
- Triple therapy has been shown to increase the risk of bleeding complications, with an annual rate of major bleeding exceeding 10% 2, 3
- Double antithrombotic therapy has been shown to reduce the rate of major and clinically relevant non-major bleeding compared with triple therapy, while being non-inferior for prevention of ischemic events 4, 2
Considerations for Elderly Patients
Elderly patients (≥80 years of age; ≥70 years of age in Japan) may require special consideration:
- The RE-DUAL PCI trial found that dual therapy with dabigatran and a P2Y12 inhibitor reduced the risk of bleeding events compared with triple therapy in elderly patients 4, 5
- However, the optimal duration of triple therapy in elderly patients may need to be individualized based on their specific clinical characteristics and risk factors 2