Variation in Triple Thrombotic Therapy

Study Questions:

Does practice variation exist in triple therapy prescribing patterns, unrelated to measured patient factors?


Using the American College of Cardiology National Cardiovascular Data Registry (NCDR) PINNACLE (National Practice Innovation and Clinical Excellence) registry, 79,875 patients with both atrial fibrillation and myocardial infarction and/or coronary stenting in the past 12 months were identified. A mixed-effects logistic regression model was used to assess patient factors and practice site to predict the use of triple therapy. Patient factors included age, sex, diabetes, congestive heart failure, hypertension, peripheral artery disease, prior stroke or transient ischemic attack, history of systemic embolism, and dyslipidemia.


Triple therapy was used by 3,568 (4.5%) of the patients with both atrial fibrillation and coronary artery disease. Of the 76,307 patients not on triple therapy, 41,316 (54.1%) were not on any anticoagulant and 65,937 (86.4%) were not on dual antiplatelet therapy. After adjusting for patient factors, a significant amount of practice variation remained for the use of triple therapy (odds ratio [OR], 2.78; 95% confidence interval [CI], 2.33-3.23). Leading patient-level predictors of triple therapy use included dyslipidemia (OR, 1.87; 95% CI, 1.69-2.08), systemic embolism (OR, 1.77; 95% CI, 148-2.12), prior stroke or transient ischemic attack (OR 1.49, 95% CI 1.36-1.64), peripheral arterial disease (OR, 1.49; 95% CI, 1.37-1.62), and male gender (OR, 1.49; 95% CI, 1.36-1.58). Age was the only patient-level negative predictor of triple therapy (OR, 0.95 per decade, 95% CI, 0.94-0.99).


The authors concluded that there is substantial practice variation in the use of triple therapy beyond what is explained by patient characteristics. The authors also concluded that opportunities exist to improve the quality of care in this population.


The authors performed a methodologically robust analysis of a large real-world observational data set for patients with both atrial fibrillation and coronary artery disease. The large practice-level variation that remains after controlling for individual patient factors suggests that further efforts could be made to improve evidence-based care. However, the greater concern is the large portion (~54%) of this population with atrial fibrillation who were not receiving anticoagulant therapy. Future efforts to reduce the practice-level variation in triple therapy should strongly consider concurrent efforts to improve the use of anticoagulants for atrial fibrillation patients.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Hypertension

Keywords: Acute Coronary Syndrome, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Coronary Artery Disease, Diabetes Mellitus, Dyslipidemias, Embolism, Heart Failure, Hypertension, Ischemic Attack, Transient, Myocardial Infarction, National Cardiovascular Data Registries, Peripheral Arterial Disease, PINNACLE Registry, Secondary Prevention, Stents, Stroke, Vascular Diseases

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