Letter by Marín et al Regarding Article, “Bleeding After Initiation of Multiple Antithrombotic Drugs, Including Triple Therapy, in Atrial Fibrillation Patients Following Myocardial Infarction and Coronary Intervention: A Nationwide Cohort Study”
Authors: Francisco Marín, Laurent Fauchier, Andrea Rubboli
Journal: Circulation (2013)

The recent article by Lamberts et al 1 shows an increased bleeding risk associated with triple therapy (TT) of aspirin, clopidogrel, and vitamin K antagonists (VKA) in patients with atrial fibrillation (AF) and high thromboembolic risk who underwent percutaneous coronary intervention and stent implantation.The authors raise the possibility that even short-term TT is hazardous with regard to bleeding risk, without a safe therapeutic window.Thus, Lamberts et al state that TT should only be prescribed after careful assessment of bleeding risk.There is lack of robust evidence about the optimal antithrombotic therapy in patients with AF who require stent implantation.Based on the results of the same real-world nationwide cohort study of patients with nonvalvular AF, the net clinical benefit was clearly in favor of VKA treatment in AF patients with increased risk of stroke/systemic embolism, regardless of bleeding risk estimation (assessed by HAS-BLED risk score). 2 The HAS-BLED bleeding risk score was calculated as the result of adding one point to hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile INR, elderly (≥65) and drugs/alcohol concomitantly (1 point for each one).Thus, the latest Update of European Guidelines in AF recommends oral anticoagulation, with either novel oral anticoagulants (ie, dabigatran, rivaroxaban, or apixaban) or VKA, for all patients with AF, except those who are at low risk (based on the CHA 2 DS 2 -VASc risk score [The CHA 2 DS 2 -VASc risk score was calculated as the result of adding 1 point to cardiac failure or dysfunction, hypertension, age ≥75 (doubled), diabetes, stroke (doubled) -vascular disease, age 65-74 and sex category (female)]). 3Evaluation of the risk of bleeding is also recommended in the Guidelines, in particular using the HAS-BLED risk score, but a high score per se should not be used to exclude oral anticoagulation therapy. 3roblems arise from the concomitant use of dual antiplatelet therapy required after stent implantation, leading to TT.Two recent Consensus Documents recommend TT in patients with AF presenting with acute coronary syndrome or those undergoing stenting, including VKA plus aspirin 100 mg per day and clopidogrel 75 mg per day in the short term, followed by longer therapy with VKA plus a single antiplatelet drug, and VKA only after 1 year from the index event. 4,5e should be very cautious with the conclusions raised by Lamberts et al. 1 The periprocedural management of antithrombotic therapy in these patients deserves great attention, but the authors do not show this information as a result of the quarantine period.Indeed the authors exclude unmeasured complications related to index hospitalization and 7 days after discharge.Renal function or use of drugeluting stents, both variables previously shown to be related to the prognosis, have not been assessed. 4An administrative dataset seems not to be the best option for controlling the continuous changes in antithrombotic therapy observed in this type of clinical scenario.Also, there is no established definition of bleeding episode in this study, and important information about the influence of HAS-BLED score in the prognosis is not provided.Although TT has been demonstrated to result in an increase in major bleeding, we suggest that the consequence should not be to withhold VKA.The key message, instead, should be to shorten the period of TT (ie, when dual antiplatelet therapy is added to VKA), limiting the duration of TT as much as possible based on clinical scenario, type of stent, and bleeding risk.