Triple antithrombotic therapy in patients with atrial fibrillation undergoing PCI: current evidence and practice

Introduction: Patients with atrial fibrillation taking oral anticoagulation and undergoing percutaneous coronary intervention with stent insertion are recommended to receive antithrombotic therapy with aspirin and P2Y₁₂ receptor antagonist. This combinatory regime encompasses triple therapy (TT). Although TT reduces the risk of ischemic events such as stroke and stent thrombosis, it is associated with an increased bleeding risk. Areas covered: The efficacy and safety profile of TT is uncertain with undetermined optimal duration and therapeutic combination. This review summarizes relevant trials evaluating TTs application and introduces exploration of duration and dosage in addition to other contributory factors including stent type and choice of antithrombotic agents. Expert commentary: TT has shown to be effective for reduction of ischemic risk. However, trials have failed to demonstrate the regime’s superiority in efficacy over alternatives such as dual therapy (single antiplatelet plus anticoagulant) and continue to denote an increased bleeding risk. Further research driven by a balance between thromboembolic and bleeding end points is required to demonstrate TTs potential beneficence, along with optimal duration identification and antithrombotic choice. Individualized patient risk stratification, along with risk factor optimization should also be incorporated.