Triple antithrombotic management after stent implantation: when and how? | Heart

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Education in Heart

Clinical pharmacology

Triple antithrombotic management after stent implantation: when and how?

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Response to Drs DeWilde and Ten Berg
Albert Schömig
Published on: 23 November 2015
Triple Therapie: proof or expert opinion?
Willem Dewilde
Published on: 23 November 2015

Published on: 23 November 2015
Response to Drs DeWilde and Ten Berg
- Albert Schömig
- Other Contributors:
  Nikolaus Sarafoff, MD and Melchior Seyfarth, MD
Randomised trials in patients on oral anticoagulation undergoing coronary stenting (response to Drs Willem Dewilde and Jurrien m ten Berg)
Dear Sir,
we agree with Dr. Dewilde and Dr. Ten Berg that current recommendations regarding coronary stenting in patients on oral anticoagulation (OAC) are not based on randomised controlled trials (RCT) and congratulate them for addressing this important issue by i...
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Randomised trials in patients on oral anticoagulation undergoing coronary stenting (response to Drs Willem Dewilde and Jurrien m ten Berg)
Dear Sir,
we agree with Dr. Dewilde and Dr. Ten Berg that current recommendations regarding coronary stenting in patients on oral anticoagulation (OAC) are not based on randomised controlled trials (RCT) and congratulate them for addressing this important issue by initiating this WOEST trail (NCT00769938). While the WOEST trial compares a triple therapy with a therapy consisting of OAC + clopidogrel, a second RCT is ongoing (ISAR-TRIPLE, NCT00776633) which evaluates the length of clopidogrel therapy (6 weeks versus 6 months) after drug eluting stent placement in patients on OAC + aspirin. These randomized trials will answer unresolved questions regarding ischemic and bleeding complications in this high risk population. In the future, we hope that the recommendations can be based on the results of these RCT’s.
Albert Schömig, MD, Nikolaus Sarafoff, MD and Melchior Seyfarth, MD
References
WOEST (What is the Optimal antiplatelet and anticoagulant therapy in patients with oral anticoagulation and coronary StenTing, clinicaltrials.gov: NCT00769938) ISAR-TRIPLE (Testing of a six-week versus a six-month clopidogrel treatment Regimen In Patients with concomitant aspirin and oraL anticoagulant therapy following drug-Eluting stenting, clinicaltrials.gov: NCT00776633)
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Conflict of Interest:
None declared.
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Published on: 23 November 2015
Triple Therapie: proof or expert opinion?
- Willem Dewilde, Cardiologist
- Other Contributors:
  Jurriën Ten Berg
We read the article by Schömig et al (1) with great interest. We learned when and how physicians should prescribe triple antithrombotic therapy after stent implantation. Schömig states that further prospective clinical trials are needed in order to evaluate the best treatment strategy for patients on oral anticoagulant therapy (OAC) who undergo percutaneous coronary interventions (PCI). Unfortunately, all present recommendati...
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We read the article by Schömig et al (1) with great interest. We learned when and how physicians should prescribe triple antithrombotic therapy after stent implantation. Schömig states that further prospective clinical trials are needed in order to evaluate the best treatment strategy for patients on oral anticoagulant therapy (OAC) who undergo percutaneous coronary interventions (PCI). Unfortunately, all present recommendations are based on expert opinion and not on randomised trials. In patients with indication for chronic oral anticoagulation who need to undergo PCI, there are theoretically four possibilities: the combinations of OAC + aspirin and aspirin + clopidogrel are unsafe because of elevated risk of stent thrombosis and stroke respectively (1,2). The combination of triple therapy, which is currently recommended, is known to elevate bleeding risk. A last possibility is the combination of OAC and clopidogrel and seems to be promising (2). Therefore a first prospective randomised international multi-centre open label trial was started on December 1, 2008 and will assess the hypothesis that after PCI with stent-implantation in patients on oral anticoagulant therapy, the combination of oral anticoagulation therapy & clopidogrel 75 mg/day is safe and not inferior to triple therapy treatment with respect to the prevention of thrombotic complications while reducing the risk of bleeding. The primary outcome is the combination of TIMI&GUSTO minor and major bleeding up to 30 days and 1 year. The secondary outcome is MACCE. The sample size is 496.Given that, to date, no prospective randomised study has yet addressed this issue, the WOEST (What is the Optimal antiplatElet & anticoagulant therapy in patients with oral anticoagulation and coronary StenTing; clinical trials.gov:NCT00769938) trial will help to define new guidelines for patients with chronic indication for chronic anticoagulation who need coronary stenting. 1.Schömig A, Sarafoff N, Seyfarth M. Triple antithrombotic management after stent implantation: when and how? Heart. 2009 Aug;95(15):1280-5. 2. Rubboli A, Halperin JL, Airaksinen KE et al. Antithrombotic therapy in patients treated with oral anticoagulation undergoing coronary artery stenting. An expert consensus document with focus on atrial fibrillation. Ann Med. 2008;40(6):428-36. Review.
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Conflict of Interest:
None declared.
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