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

     

    The correct answer is B. Dabigatran 110 mg plus P2Y12 inhibitor (clopidogrel or ticagrelor).

    The RE-DUAL PCI trial, presented in August at the European Society of Cardiology Congress 2017, randomized 2725 patients with AF who had undergone PCI to triple therapy with warfarin plus a P2Y12 inhibitor (clopidogrel or ticagrelor) and aspirin (for 1 to 3 months) (triple-therapy group) or dual therapy with dabigatran (110 mg or 150 mg twice daily) plus a P2Y12 inhibitor (clopidogrel or ticagrelor) and no aspirin (110-mg and 150-mg dual-therapy groups). Aspirin plus rivaroxaban is not a regimen that has been studied.

    The findings of RE-DUAL PCI concluded that “triple therapy” (option A) resulted in the highest rate of major or clinically relevant nonmajor bleeding (26.9% vs the 110 mg dual therapy group [option B]) and 20.2% in the 150 mg dual therapy group (option C). Both dual therapy options met the noninferiority endpoint for bleeding compared to warfarin and the 110 mg option was also significant for superiority. The trial also reported that the incidence of the composite efficacy endpoint of thromboembolic events (myocardial infarction, stroke, or systemic embolism), death, or unplanned revascularization was non-inferior in the triple therapy arm (13.4%) compared with a composite of the dual therapy arms (13.7%), suggesting the combination of dabigatran (either 110 mg or 150 mg) combined with P2Y12 inhibitor offers the best balance of safety and efficacy.

     

    References

    1. Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013 30;381 (9872):1107-15. doi: 10.1016/S0140-6736(12)62177-1. Epub 2013 Feb 13

    2. Dans AL, Connolly SJ, Wallentin L, et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trialCirculation. 2013;127:634-640.

    3. Cannon CP, Bhatt DL, Oldgren J, et al for the RE-DUAL PCI Steering Committee and Investigators. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. NEJM. Published online August 27, 2017. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa1708454#t=article

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

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