Triple Therapy for Acute Myocardial Infarction and Atrial Fibrillation

Study Questions:

What is the best antithrombotic regimen after percutaneous coronary intervention (PCI) in patients with myocardial infarction (MI) and atrial fibrillation (AF)?


This study examined 4,959 patients ≥65 years old (mean age 78 years) with acute MI and AF enrolled in the Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines registry. Outcomes were compared between 1,370 patients discharged on warfarin plus dual antiplatelet therapy (DAPT), and 3,589 patients discharged on DAPT without warfarin. The primary outcomes were major adverse cardiac events (MACE) at 2 years (death, MI, stroke) and bleeding requiring hospitalization.


There was no significant difference in the cumulative incidence of MACE between the triple therapy group (32.6%) and the DAPT group (32.7%). The incidence of bleeding requiring hospitalization was significantly higher in the triple therapy group (17.6%) than in the DAPT group (11%).


Compared to DAPT, the combination of DAPT plus warfarin increases the risk of major bleeding without affecting the risk of death, MI, or stroke.


Given the solid evidence that DAPT is inferior to warfarin for stroke prevention in AF, it is unclear why the stroke rate was not higher in the DAPT group than in the triple therapy group. In a study of 573 patients on an oral anticoagulant (OAC) who underwent PCI (Dewilde, et al., Lancet 2013;381:1107-15) and were randomly assigned to also receive clopidogrel or clopidogrel/aspirin, there was no difference in the incidence of thrombotic events, but the bleeding risk was significantly higher in the triple therapy group (44%) than in the OAC plus clopidogrel group (19%). Therefore, warfarin/clopidogrel may be an appropriate alternative to aspirin/clopidogrel after PCI in AF patients.

Keywords: Acute Coronary Syndrome, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Geriatrics, Myocardial Infarction, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Primary Prevention, Stroke, Warfarin

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