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Triple therapy with dual antiplatelet treatment and direct oral anticoagulants

      In their recent review, Dezsi et al. [
      • Dézsi C.A.
      • Dézsi B.B.
      • Dézsi D.A.
      Antithrombotic treatment in anticoagulated atrial fibrillation patients undergoing percutaneous coronary intervention.
      ] summarize the evidence on antithrombotic treatment in patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) with stenting, arguably the most common clinical situation requiring triple therapy (dual antiplatelet [DAPT] and anticoagulant treatment). This topic is of renewed relevance since the introduction of direct oral anticoagulants (DOACs), which are now commonly employed for stroke prevention in AF. Their use as part of triple therapy is less well-established due to both a lack of evidence in this setting as well as evidence of increased bleeding with limited benefit in patients with acute coronary syndrome [
      • Oldgren J.
      • Budaj A.
      • Granger C.B.
      • Khder Y.
      • Roberts J.
      • Siegbahn A.
      • et al.
      Dabigatran vs. placebo in patients with acute coronary syndromes on dual antiplatelet therapy: a randomized, double-blind, phase II trial.
      ,
      • Hess C.N.
      • James S.
      • Lopes R.D.
      • Wojdyla D.M.
      • Neely M.L.
      • Liaw D.
      • et al.
      Apixaban plus mono versus dual antiplatelet therapy in acute coronary syndromes: insights from the APPRAISE-2 trial.
      ]. Furthermore, the evidence on the use of (and the optimal length of) triple therapy for non-coronary stenting (such as endovascular treatment of cerebral arterial aneurysms) is also scarce, and is likely to remain so due to insufficient number of patients for large trials. Therefore, we believe the study by Dans et al. [
      • Dans A.L.
      • Connolly S.J.
      • Wallentin L.
      • Yang S.
      • Nakamya J.
      • Brueckmann M.
      • et al.
      Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial.
      ], who analyzed the subgroup of patients receiving antiplatelet therapy in the RE-LY (Dabigatran versus warfarin in patients with atrial fibrillation) study [
      • Connolly S.J.
      • Ezekowitz M.D.
      • Yusuf S.
      • Eikelboom J.
      • Oldgren J.
      • Parekh A.
      • et al.
      Dabigatran versus warfarin in patients with atrial fibrillation.
      ], is of great practical value. In their otherwise clearly written and well-documented review, Dezsi et al. [
      • Dézsi C.A.
      • Dézsi B.B.
      • Dézsi D.A.
      Antithrombotic treatment in anticoagulated atrial fibrillation patients undergoing percutaneous coronary intervention.
      ] failed to underscore its importance (although they did refer to the study).

      Keywords

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      Linked Article

      • Triple therapy with dual antiplatelet treatment and direct oral anticoagulants. Author's reply
        European Journal of Internal MedicineVol. 47
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          We would like to thank Sorigue et al. [1] for their interest in our article on the antithrombotic management of patients with atrial fibrillation (AF) who require percutaneous coronary intervention (PCI) with stenting [2], as well as for their valuable remarks. We appreciate the opportunity to further discuss the potential role of direct oral anticoagulants (DOACs) as a part of triple therapy in this commonly encountered clinical setting.
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