Dual vs. Triple Antithrombotics in Patients Undergoing PCI

Study Questions:

What are the outcomes associated with use of dual versus triple antithrombotic therapy for patients following percutaneous coronary intervention (PCI)?


The authors performed a meta-analysis of observational and randomized, controlled trials comparing triple therapy (dual antiplatelet plus anticoagulant) versus dual therapy (single antiplatelet plus anticoagulant) in patients taking long-term anticoagulants following PCI. Major bleeding was the primary outcome.


Nine observational studies and two randomized, controlled trials with a total of 7,276 patients were included (mean follow-up 10.8 months). Major bleeding was higher in the triple therapy versus dual therapy groups (6.6% vs. 3.8%, risk ratio [RR], 1.54; 95% confidence interval [CI], 1.2-1.98; p < 0.01). No difference was detected for all-cause mortality (RR, 0.98; 95% CI, 0.68-1.43), major adverse cardiac events (RR, 1.03; 95% CI, 0.8-1.32), thromboembolic events (RR, 1.02; 95% CI, 0.49-2.10), myocardial infarction (RR, 0.85; 95% CI, 0.67-1.09), stent thrombosis (RR, 0.77; 95% CI, 0.46-1.3), or target vessel revascularization (RR, 0.87; 95% CI, 0.66-1.15).


The authors concluded that patients on chronic anticoagulant therapy who undergo PCI may have less bleeding without a difference in mortality or thrombotic risk by using a dual antithrombotic strategy rather than triple therapy.


This well-conducted meta-analysis confirms our prior understanding that use of multiple antithrombotic agents confers a greater bleeding risk for patients. However, the benefit of this meta-analysis is that thrombotic risk such as myocardial infarction and target vessel revascularization rates were not higher in the dual therapy group. While none of the prospective studies included were specifically designed (or powered) to assess these outcomes, the pooled meta-analysis data from both prospective and retrospective studies does provide some reassurance for clinicians.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias

Keywords: Anticoagulants, Fibrinolytic Agents, Hemorrhage, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Primary Prevention, Risk, Stents, Thromboembolism, Thrombosis, Treatment Outcome

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