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Clinical pharmacology
Triple antithrombotic management after stent implantation: when and how?
  1. Albert Schömig,
  2. Nikolaus Sarafoff,
  3. Melchior Seyfarth
  1. Deutsches Herzzentrum München and 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Germany
  1. Professor Albert Schömig, Deutsches Herzzentrum München, Lazarettstr. 36, 80636 Munich, Germany; aschoemig{at}

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Inhibition of platelet activation is a cornerstone of adjunctive medical treatment during and after percutaneous coronary interventions with stent implantation (PCI-S) in order to prevent acute and long term thrombotic complications. Dual antiplatelet therapy (DAT) with aspirin and clopidogrel has been proven to be very effective at preventing adverse events such as acute and subacute stent thrombosis, myocardial infarction, and death after coronary stenting, for both bare metal stents (BMS) and drug eluting stents (DES). Oral anticoagulation (OAC) is the recommended treatment for patients at risk of thromboembolic events due to atrial fibrillation, mechanical heart valves, deep vein thrombosis, pulmonary embolism and left ventricular thrombi. The number of patients who have an indication for both DAT and OAC is increasing, since more patients who are already on OAC are scheduled for percutaneous coronary interventions and some patients who are on DAT will develop a medical condition which requires OAC. Consequently, these patients need triple antithrombotic therapy, consisting of aspirin, clopidogrel and OAC. There is a concern, however, that this “triple therapy” leads to increased bleeding events and physicians are cautious in prescribing the combination of DAT and OAC.

In the first part of this article, we review the studies and present the evidence that have led to the current recommendations for either DAT or OAC in the specific medical conditions. We will evaluate when OAC and DAT might be interchangeable, and whether one or the other of these regimens might be temporarily discontinued. We will focus on patients requiring OAC with a recent stent implantation or who are scheduled for a PCI-S. The second part of this review focuses on the currently available data on triple therapy and will provide guidance on how to manage these patients and how long the duration of treatment should be.


Dual antiplatelet therapy with …

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  • Competing interests: In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. The authors have no competing interests.