Optimal Discharge Antithrombotic Regimen
This patient should be discharged on warfarin plus clopidogrel (dual therapy), with aspirin discontinued at discharge. 1
Rationale for Dual Therapy (Warfarin + Clopidogrel)
The 2020 ACC Expert Consensus strongly recommends discontinuing aspirin prior to or upon discharge in most patients with atrial fibrillation undergoing PCI, continuing only oral anticoagulation plus a P2Y12 inhibitor. 1
For patients presenting with ACS (as this patient did with NSTEMI) who require oral anticoagulation for AF, single antiplatelet therapy with a P2Y12 inhibitor should be continued for 12 months after PCI, combined with the oral anticoagulant. 1
Clopidogrel is the preferred P2Y12 inhibitor over ticagrelor or prasugrel in patients requiring oral anticoagulation, due to lower bleeding risk. 1, 2
Why Not Triple Therapy?
Triple therapy (warfarin + aspirin + clopidogrel) dramatically increases major bleeding risk to 7.4-10.3% at 12 months, compared to dual therapy regimens. 1
Current evidence from multiple trials demonstrates that dual therapy (oral anticoagulant + P2Y12 inhibitor) provides equivalent ischemic protection with significantly less bleeding compared to triple therapy. 3, 4
Aspirin should only be continued beyond discharge in patients at very high thrombotic risk with acceptable bleeding risk, and even then only for up to 1 month maximum. 4 This patient does not meet criteria for extended triple therapy.
Warfarin vs. DOAC Consideration
While DOACs are generally preferred over warfarin due to lower bleeding risk 1, this patient was already established on warfarin with (presumably) good INR control prior to admission.
For patients already on a VKA with good INR control, continuation of the VKA post-PCI is reasonable, particularly if the patient has been compliant and has not experienced complications. 1
If continuing warfarin, target INR should be at the lower end of the therapeutic range (2.0-2.5) with more frequent monitoring to reduce bleeding risk. 1, 2
However, switching to a DOAC (specifically apixaban or rivaroxaban) would be the preferred option if feasible, as these agents have demonstrated lower bleeding rates in the AF post-PCI population. 1
Duration of Therapy
Dual therapy (anticoagulant + clopidogrel) should continue for 12 months given the ACS presentation. 1, 4
After 12 months, transition to oral anticoagulation monotherapy (warfarin alone or preferably a DOAC) for lifelong stroke prevention. 1
Essential Bleeding Risk Mitigation
A proton pump inhibitor must be prescribed for all patients on dual antithrombotic therapy to reduce gastrointestinal bleeding risk. 1, 2
NSAIDs must be strictly avoided as they further increase bleeding risk. 2
INR monitoring should be more frequent than usual if continuing warfarin, with careful attention to time in therapeutic range. 1
Common Pitfall to Avoid
The most critical error would be discharging this patient on triple therapy (warfarin + aspirin + clopidogrel) for an extended duration. While older guidelines from 2010 recommended prolonged triple therapy 1, the most recent 2020-2021 ACC guidelines based on contemporary trial data clearly demonstrate that aspirin should be discontinued at or shortly after discharge in most patients. 1, 4 The bleeding risk of prolonged triple therapy far outweighs any marginal ischemic benefit in the modern stent era.