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    Aspirin, Clopidogrel, DOAC, Warfarin: What Combination after PCI in Patients with AF?


    The correct answer is D. WOEST

    Until recently, so-called “triple therapy”—a combination of dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) and a vitamin-K antagonist—was preferred. Although “all bases were covered” with this strategy (ie, thrombin and platelet inhibition), it resulted in significantly high rates of bleeding, especially among the elderly. Newer strategies have emerged to help reduce this risk. Among these is the strategy investigated in the WOEST study, thus WOEST strategy, in which aspirin is dropped and platelet inhibition is achieved using monotherapy with a P2Y12 inhibitor plus an oral anticoagulant after PCI. Study authors, writing in the Lancet, concluded, “Use of clopidogrel without aspirin was associated with a significant reduction in bleeding complications and no increase in the rate of thrombotic events.” An important caveat about the study is that use of radial access was low, which may have artificially inflated the rates of bleeding in the triple therapy arm. This practice is not based on clinical experience.

    RE-LY (option B) was a randomized trial of warfarin vs two doses of dabigatran in patients with non-valvular AF. BRIDGE-AF (option C) addresses perioperative bridging in patients with AF on anticoagulation.

    2. True or False? Data show that the combination of a direct oral anticoagulant (DOAC) and dual antiplatelet therapy is associated with lower bleeding compared with use of dual antiplatelet therapy with a vitamin-K antagonist (ie, warfarin).

    A. True

    B. False

    Please click here for answer, discussion, next question.

    Payal Kohli, MD
    Payal Kohli, MD, is an attending cardiologist for Kaiser Permanente in Denver, Colorado.


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