The antithrombotic management of patients on oral anticoagulation undergoing coronary stent implantation: an update

Triple therapy (TT) of warfarin, aspirin, and clopidogrel is currently recommended as the optimal antithrombotic treatment in patients on long-term oral anticoagulation (OAC) for clinical conditions at moderate–high thromboembolic risk, such as moderate-high risk atrial fibrillation, mechanical heart valve, cardiogenic embolism, etc., who undergo coronary stent implantation. While being recognized as the most effective treatment for preventing major adverse cardiac events, stent thrombosis and stroke, TT is associated with an increased risk of bleeding, which apparently increases as the duration of TT is prolonged. Available evidence, however, is flawed by important limitations, including the limited size and retrospective design of most of the studies, as well as, the underreporting of the treatment that was actually ongoing at the time of an event. Recent data derived from larger, prospective studies have broadened and strengthened the recommendations that have been earlier issued by Scientific Associations. While confirming the overall superior net clinical benefit of TT in patients at moderate-high thromboembolic risk, recent data suggest that: (1) TT is likely associated with minor rather than major bleeding complications, and (2) accurate stratification of thromboembolic and bleeding risk may allow optimization of the antithrombotic treatment at discharge. Therefore, while still awaiting well designed, prospective, randomized trials, current data indicate that TT is the treatment of choice for patients on OAC at moderate-high thromboembolic risk, provided that meticulous review is frequently carried out in order to minimize and to detect early bleeding complications, while discontinuation of OAC and substitution with dual antiplatelet treatment is warranted in low-risk patients.