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Increased use of antithrombotic agents increases hospital admissions for bleeding
The safety of multiple antithrombotic drug regimes has not been fully investigated in clinical trials. In particular, guidelines for the management of patients with myocardial infarction (MI) who also have an indication for warfarin are currently unclear; some recommend the use of clopidogrel and warfarin in combination following coronary stent implantation. As bleeding episodes following MI are associated with increased morbidity and mortality, the use of such treatment combinations raises concerns.
Sorensen and colleagues used nationwide registers from Denmark to identify 40 812 patients who had been admitted to hospital with first-time MI between 2000 and 2005. The authors examined the prescriptions started at discharge to divide the patients into groups of: monotherapy with aspirin, clopidogrel, or warfarin; dual therapy with any two of the preceeding agents; or triple therapy. The risk of hospital admission for bleeding, recurrent MI and death were assessed by Cox proportional hazards models with the drug exposure groups as time-varying covariates. The main results are summarised in table 1 and show that clopidogrel combined with warfarin substantially raises the yearly incidence of bleeding.