BioMed Research International / 2018 / Article / Tab 3

Review Article

Optimum Antithrombotic Therapy in Patients Requiring Long-Term Anticoagulation and Undergoing Percutaneous Coronary Intervention

Table 3

Guideline recommendations regarding triple therapy.

Class of evidence 2016 European Society of Cardiology Guidelines on AF [43]2014 European Consensus on AF and PCI [4]2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease [6]2014 ACC/AHA Guidelines on NSTEMI [44]2013 ACC/AHA Guidelines on STEMI [45]

Summary and synthesis of guideline, expert consensus documents, and comprehensive review article recommendations(1) Keep TT duration as short as possible
(2) Consider target INR 2.0–2.5 when warfarin is used as part of TT
(3) Clopidogrel is the P2Y12 inhibitor of choice
(4) PPIs should be used in patients with history of GI bleeding and those who are at high risk of bleeding while being on TT

(I)(1) After ACS or PCI: OAC monotherapy after initial 12 months
(2) After elective PCI: OAC monotherapy after initial 6 months in patients with high bleeding risk
(1) Minimize duration of TT to limit risk of bleeding
(2) Addition of PPI therapy in patients with prior history of GI bleeding who are started on TT

(IIa)(1) Stable CAD with elective PCI: 1 month of TT
(2) Stenting after ACS: 1–6 months of TT
(3) ACS without stenting: up to 12 months of DT
(4) In general, minimize duration of TT and after completion of TT, DT until 12 months after PCI or ACS
(1) Stable CAD with elective PCI: 1–6 months of TT
(2) ACS: 1–6 months of TT
(3) After completion of TT, DT until 12 months after PCI or ACS
(4) Consider lower iNR goal for warfarin (2.0–2.5) when part of TT
Consider addition of PPI therapy in patients without prior history of GI disturbances who are started on TT

(IIb)DT with OAC + clopidogrel may be considered as an alternative therapy in selective patients(1) DT with OAC + clopidogrel may be considered as an alternate to TT in selected patients
(2) ACS: 6–12 months of TT if low bleeding risk
(3) DT beyond 12 months after ACS in selected cases (LM lesions, proximal LAD lesions, recurrent MIs, etc.)
(4) When using DOAC as part of TT, we may consider lower tested dose of DOAC for stroke prevention in AF
Consider lower INR goal (2–2.5) for patients receiving ASA and P2Y12 inhibitorConsider lower INR goal (2–2.5) for patients receiving ASA and P2Y12 inhibitor

(III)Ticagrelor and Prasugrel should not be part of TT

AF = atrial fibrillation, PCI = percutaneous coronary intervention, ACC/AHA = American College of Cardiology/American Heart association, NSTEMI = non-ST-elevation myocardial infarction, STEMI = ST-elevation myocardial infarction, TT = triple therapy, INR = international normalized ratio, PPI = proton pump inhibitor, GI = gastrointestinal, ACS = acute coronary syndrome, OAC = oral anticoagulant, CAD = coronary artery disease, DT = dual therapy, LM = left main, LAD = left anterior descending, MI = myocardial infarction, DOAC = direct oral anticoagulant, and ASA = aspirin.