When and how should a nurse use Triad (combination therapy) in patient care?

When and How to Use Triad in Patient Care

Triple therapy (Triad) should be used for patients with atrial fibrillation who undergo percutaneous coronary intervention, with the standard duration being 1 month for most patients and up to 6 months only in those with very high ischemic risk that outweighs bleeding risk. 1

Primary Indications for Triple Therapy

• Triple therapy is indicated for patients with atrial fibrillation who undergo percutaneous coronary intervention (PCI), especially those with high thrombotic risk features 1
• Patients with recent acute coronary syndrome with stent placement who have a concomitant indication for oral anticoagulation (such as atrial fibrillation, mechanical heart valve, or venous thromboembolism) should receive triple therapy 1
• High ischemic risk due to anatomical or procedural characteristics that outweigh bleeding risk, such as complex PCI, bifurcation lesions, or multiple stents, may warrant triple therapy 1

Medication Selection for Triple Therapy

• Triple therapy consists of an oral anticoagulant plus dual antiplatelet therapy (DAPT) 1
• Non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists, using the lowest approved dose effective for stroke prevention 1
• Clopidogrel is the only recommended P2Y12 inhibitor for triple therapy, while ticagrelor and prasugrel should be avoided due to higher bleeding risk 1
• Low-dose aspirin (75-100mg daily) should be used as part of triple therapy 1

Duration of Triple Therapy

• The standard duration of triple therapy is 1 month, irrespective of stent type 1
• Extended duration of up to 6 months may be considered only in patients with very high ischemic risk that outweighs bleeding risk 1
• After the triple therapy period, transition to dual therapy with oral anticoagulant and single antiplatelet for up to 12 months, followed by oral anticoagulant alone 1

Risk Mitigation Strategies

• Proton pump inhibitors should be routinely used to reduce gastrointestinal bleeding risk 1
• For patients with high bleeding risk, consider avoiding triple therapy altogether and use dual therapy with oral anticoagulant and clopidogrel instead 1
• Regular assessment of both thrombotic and bleeding risks is essential throughout the treatment period 1

Nursing Considerations When Administering Triple Therapy

• Nurses should monitor for signs of bleeding, including checking for bruising, blood in urine or stool, and unusual bleeding from gums or nose 1
• Patient education is critical - nurses should ensure patients understand the importance of medication adherence and recognizing bleeding signs 1
• Nurses should verify that gastroprotection with proton pump inhibitors is prescribed and taken by the patient 1
• Medication reconciliation is essential to prevent drug interactions that may increase bleeding risk 1
• Nurses should document and communicate any signs of bleeding immediately to the healthcare team 1

Common Pitfalls to Avoid

• Prolonging triple therapy beyond necessary duration should be avoided; use the shortest effective period 1
• Using prasugrel or ticagrelor as part of triple therapy should be avoided due to significantly increased bleeding risk 1
• Failing to reassess thrombotic and bleeding risks periodically during treatment 1
• Not using gastroprotection with proton pump inhibitors during triple therapy 1
• Overlooking the transition plan from triple therapy to dual therapy and eventually to monotherapy 1

Recent Evidence and Evolving Practice

• Recent evidence suggests dual therapy with oral anticoagulant and P2Y12 inhibitor may be non-inferior to triple therapy for preventing thrombotic events while causing significantly less bleeding 1
• Current guidelines recommend against routine use of triple therapy for most patients, with dual therapy being the default strategy for many patients 1
• The nurse's role in monitoring and educating patients on this complex medication regimen is critical to prevent adverse outcomes 1