Combined Oral Anticoagulants and Antiplatelets: Benefits and Risks

Overview

Journal Intern Emerg Med

Publisher Springer

Specialties Emergency Medicine
General Medicine

Date 2010 Feb 12

PMID 20148368

Citations 2

Authors

Maria Cristina Vedovati

Cecilia Becattini

Giancarlo Agnelli

Affiliations

Soon will be listed here.

Abstract

Combined antiplatelet and anticoagulant therapy has been suggested for those clinical conditions in which conventional antithrombotic regimens have shown suboptimal efficacy, and in patients with indication for both: antiplatelet and anticoagulant therapy. Clinical trials aimed at assessing the clinical benefit of the association with respect to mono-therapy have been conducted in patients with atrial fibrillation, in patients with recent myocardial infarction, and in patients with prosthetic heart valves. Overall, a favorable benefit-risk profile of combined therapy in comparison to anticoagulant alone has been observed in patients with mechanical prosthetic heart valves and in those with coronary artery disease while no clear advantage has been shown in patients with atrial fibrillation. In almost all these studies, however, a higher risk of major bleeding has been observed in patients receiving combined therapy in comparison to patients receiving warfarin alone. Thus, a combined regimen of anticoagulant and antiplatelet therapy should be reserved for selected patients at high risk of thromboembolic events who have a low risk of bleeding.

Citing Articles

The antithrombotic management of patients on oral anticoagulation undergoing coronary stent implantation: an update.

Rubboli A Intern Emerg Med. 2011; 7(4):299-304.

PMID: 21387196 DOI: 10.1007/s11739-011-0555-1.

Combined oral anticoagulant and antiplatelet treatment: need for an evidence-based approach.

Moia M Intern Emerg Med. 2010; 5(4):275-6.

PMID: 20574756 DOI: 10.1007/s11739-010-0418-1.

References

Rubboli A, Di Pasquale G . Triple therapy of warfarin, aspirin and a thienopyridine for patients treated with vitamin K antagonists undergoing coronary stenting. A review of the evidence. Intern Emerg Med. 2007; 2(3):177-81. DOI: 10.1007/s11739-007-0055-5. View

Manzano-Fernandez S, Pastor F, Marin F, Cambronero F, Caro C, Pascual-Figal D . Increased major bleeding complications related to triple antithrombotic therapy usage in patients with atrial fibrillation undergoing percutaneous coronary artery stenting. Chest. 2008; 134(3):559-567. DOI: 10.1378/chest.08-0350. View

. The effects of oral anticoagulants in patients with peripheral arterial disease: rationale, design, and baseline characteristics of the Warfarin and Antiplatelet Vascular Evaluation (WAVE) trial, including a meta-analysis of trials. Am Heart J. 2005; 151(1):1-9. DOI: 10.1016/j.ahj.2005.03.021. View

Turpie A, Gent M, Laupacis A, Latour Y, Gunstensen J, Basile F . A comparison of aspirin with placebo in patients treated with warfarin after heart-valve replacement. N Engl J Med. 1993; 329(8):524-9. DOI: 10.1056/NEJM199308193290802. View

Orford J, Fasseas P, Melby S, Burger K, Steinhubl S, Holmes D . Safety and efficacy of aspirin, clopidogrel, and warfarin after coronary stent placement in patients with an indication for anticoagulation. Am Heart J. 2004; 147(3):463-7. DOI: 10.1016/j.ahj.2003.06.004. View

Wang T, Robinson L, Ou F, Roe M, Ohman E, Gibler W . Discharge antithrombotic strategies among patients with acute coronary syndrome previously on warfarin anticoagulation: physician practice in the CRUSADE registry. Am Heart J. 2008; 155(2):361-8. DOI: 10.1016/j.ahj.2007.09.003. View

Estes 3rd N, Halperin J, Calkins H, Ezekowitz M, Gitman P, Go A . ACC/AHA/Physician Consortium 2008 Clinical Performance Measures for Adults with Nonvalvular Atrial Fibrillation or Atrial Flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the.... J Am Coll Cardiol. 2008; 51(8):865-84. DOI: 10.1016/j.jacc.2008.01.006. View

Hart R, Benavente O, McBride R, Pearce L . Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med. 1999; 131(7):492-501. DOI: 10.7326/0003-4819-131-7-199910050-00003. View

Flaker G, Gruber M, Connolly S, Goldman S, Chaparro S, Vahanian A . Risks and benefits of combining aspirin with anticoagulant therapy in patients with atrial fibrillation: an exploratory analysis of stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) trials. Am Heart J. 2006; 152(5):967-73. DOI: 10.1016/j.ahj.2006.06.024. View

10.

Marietta M, Pedrazzi P, Girardis M, TORELLI G . Intracerebral haemorrhage: an often neglected medical emergency. Intern Emerg Med. 2007; 2(1):38-45. PMC: 2780614. DOI: 10.1007/s11739-007-0009-y. View

11.

Cannegieter S, Rosendaal F, Wintzen A, van der Meer F, Vandenbroucke J, Briet E . Optimal oral anticoagulant therapy in patients with mechanical heart valves. N Engl J Med. 1995; 333(1):11-7. DOI: 10.1056/NEJM199507063330103. View

12.

van den Bergh P, Kievit P, Brouwer M, Aengevaeren W, Veen G, Verheugt F . Prolonged anticoagulation therapy adjunctive to aspirin after successful fibrinolysis: from early reduction in reocclusion to improved long-term clinical outcome. Am Heart J. 2009; 157(3):532-40. DOI: 10.1016/j.ahj.2008.11.008. View

13.

Connolly S, Ezekowitz M, Yusuf S, Eikelboom J, Oldgren J, Parekh A . Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009; 361(12):1139-51. DOI: 10.1056/NEJMoa0905561. View

14.

Johnson W, Williford W . Benefits, morbidity, and mortality associated with long-term administration of oral anticoagulant therapy to patients with peripheral arterial bypass procedures: a prospective randomized study. J Vasc Surg. 2002; 35(3):413-21. DOI: 10.1067/mva.2002.121847. View

15.

Rossini R, Musumeci G, Lettieri C, Molfese M, Mihalcsik L, Mantovani P . Long-term outcomes in patients undergoing coronary stenting on dual oral antiplatelet treatment requiring oral anticoagulant therapy. Am J Cardiol. 2008; 102(12):1618-23. DOI: 10.1016/j.amjcard.2008.08.021. View

16.

Sobel M, Verhaeghe R . Antithrombotic therapy for peripheral artery occlusive disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133(6 Suppl):815S-843S. DOI: 10.1378/chest.08-0686. View

17.

Dentali F, Douketis J, Lim W, Crowther M . Combined aspirin-oral anticoagulant therapy compared with oral anticoagulant therapy alone among patients at risk for cardiovascular disease: a meta-analysis of randomized trials. Arch Intern Med. 2007; 167(2):117-24. DOI: 10.1001/archinte.167.2.117. View

18.

Douketis J, Arneklev K, Goldhaber S, Spandorfer J, Halperin F, Horrow J . Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case-fatality rate, time course and sites of bleeding, and risk factors for bleeding. Arch Intern Med. 2006; 166(8):853-9. DOI: 10.1001/archinte.166.8.853. View

19.

Singer D, Albers G, Dalen J, Fang M, Go A, Halperin J . Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133(6 Suppl):546S-592S. DOI: 10.1378/chest.08-0678. View

20.

Sarac T, Huber T, Back M, Ozaki C, Carlton L, Flynn T . Warfarin improves the outcome of infrainguinal vein bypass grafting at high risk for failure. J Vasc Surg. 1998; 28(3):446-57. DOI: 10.1016/s0741-5214(98)70130-2. View