Complex antithrombotic combinations: how to find the perfect blend?

Patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) present a frequent clinical dilemma if they also have atrial fibrillation (AF). They require antiplatelet therapy to prevent stent thrombosis and recurrent myocardial infarction (MI), but also require anticoagulation as stroke prophylaxis for AF.1 However, the optimal combination of aspirin, platelet P2Y12 inhibitor and anticoagulant is still unknown, and a one-size-fits-all approach may never be possible. We now have five randomised controlled trials on this topic—so what have they taught us? We have learnt that discontinuation of aspirin significantly reduces the risk of major bleeding,2 with a possible trend towards a small increase in risk of recurrent MI and stent thrombosis.3 We have also learnt that apixaban,2 and likely all of the current non-vitamin K oral anticoagulants (NOAC),3 4 reduce the risk of major bleeding compared with warfarin in this setting. So what do we have left to learn? One major outstanding issue is the optimal choice of platelet P2Y12 inhibitor. In patients without AF, ticagrelor and prasugrel have largely superseded clopidogrel in the treatment of ACS. Compared with clopidogrel, …