Does a patient on oral anticoagulation (anticoagulant) presenting with Non-ST-Elevation Myocardial Infarction (NSTEMI) require all three components of Dual Antiplatelet Therapy (DaPT), which includes aspirin and a P2Y12 (platelet inhibitor) inhibitor?

Management of Triple Antithrombotic Therapy in NSTEMI Patients on Oral Anticoagulation

Yes, patients on oral anticoagulation presenting with NSTEMI typically require triple therapy (oral anticoagulant plus dual antiplatelet therapy), but the duration should be minimized to limit bleeding risk. 1

Initial Antithrombotic Strategy

• Triple antithrombotic therapy consisting of a vitamin K antagonist (or other oral anticoagulant), aspirin, and a P2Y12 receptor inhibitor is indicated for patients with NSTEMI who are already on oral anticoagulation 1
• The duration of triple therapy should be minimized to the extent possible to limit the risk of bleeding, which can increase from 4-6% with dual therapy to 10-14% with triple therapy 1
• Aspirin should be continued indefinitely with a maintenance dose of 81 mg daily in patients treated with ticagrelor and 81-325 mg daily in all other patients 1

P2Y12 Inhibitor Selection

• For patients requiring triple therapy, clopidogrel is the preferred P2Y12 inhibitor over prasugrel or ticagrelor due to lower bleeding risk 1
• In patients undergoing PCI who are not at high risk for bleeding complications, prasugrel may be reasonable to choose over clopidogrel 1
• Ticagrelor is reasonable to use in preference to clopidogrel for patients undergoing an early invasive or ischemia-guided strategy, but this must be balanced against the increased bleeding risk in triple therapy 1

Duration of Triple Therapy

• Triple therapy should be kept as short as possible, typically for 1 week to 1 month (often until hospital discharge), followed by dual therapy with an oral anticoagulant plus a P2Y12 inhibitor (preferably clopidogrel) for up to 12 months 2
• After 12 months, patients can transition to oral anticoagulant monotherapy 2
• If the risk of morbidity from bleeding outweighs the anticipated benefit of a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (<12 months) of P2Y12 inhibitor therapy is reasonable 1

Bleeding Risk Reduction Strategies

• Proton pump inhibitors should be prescribed in patients with NSTEMI with a history of gastrointestinal bleeding who require triple antithrombotic therapy 1, 3
• Proton pump inhibitor use is reasonable even in patients without a known history of gastrointestinal bleeding who require triple antithrombotic therapy 1
• Targeting oral anticoagulant therapy to a lower international normalized ratio (INR) (e.g., 2.0 to 2.5) may be reasonable in patients with NSTEMI managed with aspirin and a P2Y12 inhibitor 1

Special Considerations

• For elderly patients (≥80 years old), the bleeding risk with triple antithrombotic therapy is substantially higher, requiring even more careful consideration of the necessity and duration of triple therapy 4
• In patients with high bleeding risk, consider shortening the duration of triple therapy to the absolute minimum necessary (even as short as during the hospital stay) 1, 3
• The HAS-BLED score should be used to assess bleeding risk and guide therapy decisions in patients requiring triple therapy 1

Common Pitfalls to Avoid

• Avoid prolonged triple therapy beyond what is absolutely necessary, as bleeding risk increases substantially with duration 1
• Don't use prasugrel as part of triple therapy in patients at high risk for bleeding (history of stroke, age ≥75 years, weight <60 kg) 1
• Don't forget to initiate a proton pump inhibitor for gastroprotection in all patients on triple therapy 1, 3
• Avoid higher maintenance doses of aspirin (>81 mg) when possible in patients on triple therapy to reduce bleeding risk 1