Combined anticoagulant and antiplatelet therapy for long-term management of acute coronary syndromes

In patients who have undergone percutaneous coronary intervention (PCI) for an acute coronary event and who have an indication for an oral anticoagulant (eg atrial fibrillation), a short period (eg 1 to 4 weeks) of triple antithrombotic therapy may be considered (eg aspirin, clopidogrel and an oral anticoagulant)Hindricks, 2021.

This would then be followed by dual antithrombotic therapy, such as an oral anticoagulant at the standard dose for stroke prevention and a single oral antiplatelet drug (preferably clopidogrel) for up to 12 months from the time of the coronary event. This should not be confused with antiplatelet plus low-intensity anticoagulant therapy for the secondary prevention of atherosclerotic cardiovascular events in patients with stable coronary artery disease.

After 12 months, antiplatelet therapy in patients treated with dual antithrombotic therapy can usually be stopped, and the oral anticoagulant alone continued.

Antithrombotic therapy with an oral anticoagulant plus a potent P2Y₁₂ inhibitor (either ticagrelor or prasugrel) can be considered as an alternative to triple antithrombotic therapy in patients with a moderate or high risk of stent thrombosis.

Whether to use 2 or 3 antithrombotic drugs initially following an acute coronary syndrome should be considered in consultation with the specialist cardiologist. This decision depends on whether PCI was undertaken, as well as the patient’s bleeding and ischaemic risk. For more information, see Antithrombotic therapy after endovascular and cardiac interventions.

Except for specific indications (mechanical prosthetic valves or moderate to severe mitral stenosis), the preferred oral anticoagulant is a direct-acting oral anticoagulant (DOAC).

A proton pump inhibitor is recommended in patients receiving triple antithrombotic therapy, see Proton pump inhibitors for patients with acute coronary syndrome.