Contemporary Use and Clinical Significance of Initial Triple Versus Double Therapy After Percutaneous Coronary Intervention for Myocardial Infarction in Patients With Atrial Fibrillation

BACKGROUND: Patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI) have traditionally received triple therapy (dual antiplatelet therapy and anticoagulation). More recent randomized trial evidence supports a strategy of double therapy (anticoagulant plus single antiplatelet agent), albeit after a brief triple therapy course. The safety of initiating double therapy immediately post-PCI remains unclear. METHODS AND RESULTS: This study analyzed real-world prescribing patterns and outcomes of immediate double therapy versus initial triple therapy in patients with atrial fibrillation post-PCI using the Vizient Clinical Database. Patients with atrial fibrillation undergoing PCI for myocardial infarction (2016-2023) were categorized into 2 groups: triple therapy (aspirin, P2Y12 [purinergic receptor P2Y, G-protein coupled, 12 protein] inhibitor, and anticoagulant) or double therapy (anticoagulant and 1 antiplatelet agent) on day 1 post-PCI. The primary outcome was in-hospital mortality. Secondary outcomes included stent thrombosis, major bleeding, intracranial hemorrhage, and net clinical adverse events. Multivariable logistic regression and inverse probability of treatment weighting were used to compare outcomes. Among 29 226 patients, 16.3% received immediate double therapy on day 1 post-PCI, whereas 83.7% received triple therapy. Adjusted analyses showed no significant differences in in-hospital mortality (9.4% versus 9.2%, adjusted odds ratio [aOR], 1.05 [95% CI, 0.93-1.18]), major bleeding, intracranial hemorrhage, or net clinical adverse events. However, immediate double therapy was associated with higher odds of stent thrombosis (1.1% versus 0.8%; aOR, 1.48 [95% CI, 1.08-2.03]), particularly in patients with ST-segment-elevation myocardial infarction (2.0% versus 1.3%; aOR, 1.46 [95% CI, 1.001-2.13]). CONCLUSIONS: Immediate double therapy post-PCI is frequently used and appears safe for most patients with atrial fibrillation. Further studies are needed to identify high-risk subgroups, including those with ST-segment-elevation myocardial infarction, who may benefit from an initial short course of triple therapy.