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Clinical pharmacology
Triple antithrombotic therapy after ACS and PCI in patients on chronic oral anticoagulation: update
  1. Davide Capodanno1,2
  1. 1 Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, Catania, Italy
  2. 2 Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
  1. Correspondence to Professor Davide Capodanno, Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania 95100, Italy; dcapodanno{at}

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Learning objectives

  • To describe the clinical risks and benefits associated with triple antithrombotic therapy.

  • To provide a state-of-the-art exposition of clinical studies in the field, including recent studies of non-vitamin K antagonist oral anticoagulants.

  • To explore clinically oriented scenarios and master the theory and practice of using combinations of anticoagulant and antiplatelet drugs.


Oral anticoagulation (OAC) with vitamin K antagonists (VKAs) is indicated for the prophylaxis and treatment of venous thrombosis and pulmonary embolism as well for the prophylaxis and treatment of thromboembolic complications associated with atrial fibrillation (AF), cardiac valve replacement and myocardial infarction. Non-vitamin K antagonist oral anticoagulants (NOACs), which are safer alternatives to VKAs and do not require laboratory monitoring, are also available for many of these indications. AF is the most common scenario where chronic OAC is required for the prevention of stroke or systemic embolism, with a prevalence of about 3% in adults aged 20 years or older, and greater prevalence in elderly and patients with predisposing factors.1 In the European guidelines for the management of AF, OAC is recommended (class I) for all male AF patients with a CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65-74, Female) score of 2 or more and all female AF patients with a CHA2DS2-VASc score of 3 or more, but should be also considered (class IIa) in male and female AF patients with CHA2DS2-VASc scores of 1 and 2, respectively.2 NOACs are regarded as first-line drug options for thromboembolic prevention in eligible patients with AF (eg, in preference to VKAs) but are not recommended for AF patients with mechanical heart valves and moderate-to-severe mitral stenosis.

The cornerstone of chronic antithrombotic prophylaxis in patients undergoing percutaneous …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests Speaker’s and consulting fees from AstraZeneca, Bayer and Sanofi-Aventis.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note References that include an asterisk (*) are considered to be key references.