NEW YORK (Reuters Health) – For patients who require stroke prevention therapy and who also undergo coronary stenting, combining oral anticoagulation with aspirin and clopidogrel provides better antithrombotic protection than dual antiplatelet therapy alone. That’s according to the results of a meta-analysis reported in the February issue of Chest.
Dr. Ming Zhong, at Qilu Hospital of Shandong University, Ji’nan, China, and colleagues point out that an increasing number of patients on long-term oral anticoagulation are also undergoing percutaneous coronary intervention, but the optimal antithrombotic regimen for such patients is unclear.
The researchers conducted a meta-analysis of nine trials covering 1,996 patients to examine the benefits and risks of triple antithrombotic therapy with aspirin, clopidogrel and oral anticoagulation — usually warfarin — versus dual antiplatelet therapy with aspirin plus clopidogrel.
“As a whole,” the authors observe, “patients who were considered at a high risk of thrombotic events or were in a complicated situation were treated with triple antithrombotic therapy, whereas patients considered at a high risk of bleeding events received only dual antiplatelet therapy in the poststenting period.”
The analysis showed that the risk of major adverse cardiovascular events (MACE), defined as cardiac death, acute myocardial infarction, stent thrombosis, or target lesion revascularization, was reduced more with triple therapy than dual therapy (odds ratio, 0.60; p=0.005).
The risk of ischemic stroke was not significantly different with either regimen, but overall stroke risk tended to be higher with dual antiplatelet therapy (OR, 0.38; p=0.11), the researchers found.
“There was a significant reduction in all-cause mortality with triple antithrombotic therapy compared with dual antiplatelet therapy (OR, 0.59; p=0.01),” according to the report.
However, major bleeding events during the first 6 months of treatment were twice as likely with triple therapy as dual therapy (OR, 2.12; p=0.04).
Overall, Dr. Zhong and colleagues conclude, “Triple therapy is currently the best option for the majority of patients, especially those with a higher risk of thrombotic events and a lower risk of bleeding events, although this therapy predisposes patients to an increased risk of bleeding.”
They add, “Major bleeding events should be treated aggressively, but inadvertent stopping of antithrombotic treatment due to minor bleeding events is not wise.”
Reference:
“Triple Therapy” Rather Than “Triple Threat”
A Meta-analysis of the Two Antithrombotic Regimens After Stent Implantation in Patients Receiving Long-term Oral Anticoagulant Treatment
CHEST 2011;139:260-270.
