Dosage of direct oral anticoagulants during dual and triple antithrombotic therapy: a focus on the net clinical benefit

The 2020 ESC guidelines on the diagnosis and management of atrial fibrillation (AF) recommend standard dosage of direct oral anticoagulants (DOACs) during triple antithrombotic therapy (TAT). Aspirin 100 mg and the P2Y12 inhibitor clopidogrel should be preferred for dual antiplatelet therapy. Discontinuation of aspirin is recommended for subsequent dual antithrombotic therapy (DAT). Dose reduction in dabigatran (110 mg b.i.d.) and rivaroxaban (15 mg o.d.) during DAT or TAT should only be considered in patients with high bleeding risk prevailing concerns about stent thrombosis.1 While TAT is associated with a lower burden of stent thrombosis and thromboembolic events, it carries an almost four-fold increased risk for major bleeding events and intracranial haemorrhage compared with DOAC monotherapy.2 The applied treatment strategy needs to balance the ischaemic risk against the risk of bleeding in order to reach a favourable net clinical benefit. With a lacking evident decision strategy, the authors feel...