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J Am Coll Cardiol. 2014 Sep 23;64(12):1270-80. doi: 10.1016/j.jacc.2014.06.1193.

Triple therapy for atrial fibrillation and percutaneous coronary intervention: a contemporary review.

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Department of Cardiology, Amphia Hospital, Breda, the Netherlands. Electronic address:
Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands.
Department of Cardiology, Onze Lieve Vrouwe Hospital (OLVG), Amsterdam, the Netherlands.
Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom.
Department of Cardiology, Gasthuisberg University Hospital Leuven, Leuven, Belgium.
Department of Cardiology, Copenhagen University Hospital Gentofte, Copenhagen, Denmark.


Chronic oral anticoagulant therapy is recommended (class I) in patients with mechanical heart valves and in patients with atrial fibrillation with a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or transient ischemic attack or thromboembolism, Vascular disease, Age 65 to 74 years, Sex category) score ≥1. When these patients undergo percutaneous coronary intervention with stenting, treatment with aspirin and a P2Y12 receptor inhibitor also becomes indicated. Before 2014, guidelines recommended the use of triple therapy (vitamin K antagonists, aspirin, and clopidogrel) for these patients. However, major bleeding is increasingly recognized as the Achilles' heel of the triple therapy regimen. Lately, various studies have investigated this topic, including a prospective randomized trial, and the evidence for adding aspirin to the regimen of vitamin K antagonists and clopidogrel seems to be weakened. In this group of patients, the challenge is finding the optimal equilibrium to prevent thromboembolic events, such as stent thrombosis and thromboembolic stroke, without increasing bleeding risk.


acenocoumarol; clopidogrel; dual antiplatelet therapy; oral anticoagulation; phenprocoumon; platelet aggregation

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