Triple antithrombotic therapy in patients with atrial fibrillation and coronary artery disease

According to current guidelines, all patients with a recent coronary artery stent placement should receive double antiplatelet therapy with a combination of aspirin plus clopidogrel to reduce the likelihood of acute and subacute stent thrombosis. The length of treatment depends on the type of the stent, with bare metal stents requiring at least 1 month and drug-eluting stents requiring 6 months of both antiplatelet drugs. The length of treatment of patients with acute coronary syndrome is 12 months of dual antithrombocite drugs. Atrial fibrillation carries a high risk for thromboembolic events and any patient with at least two moderate risk factors should be on oral anticoagulation with a vitamin K antagonist. Since atrial fibrillation and coronary artery disease with stent placement are common, it is not infrequent to treat patients with both these conditions, where triple antithrombotic therapy with aspirin, clopidogrel and oral antagonist of vitamin K would be needed. However, concerns about increased bleeding risk do exist and clinicians are uncertain about how to manage this diffi cult clinical situation-especially since there are no large randomised trials to guide clinical practice regarding this particular issue.