News | Antiplatelet and Anticoagulation Therapies | August 04, 2015

No Benefit in Adding Third Antiplatelet Drug for Older Patients

Study finds triple therapy has same event rate, more bleeding than dual antiplatelet therapy in patients with atrial fibrillation, heart attack

triple therapy, dual antiplatelet therapy, atrial fibrillation, heart attack, older patients, JACC

August 4, 2015 — Triple therapy is no better than dual antiplatelet therapy in preventing major adverse cardiac events in older patients with atrial fibrillation who had a heart attack treated with angioplasty, according to a new study. The study, published in the Journal of the American College of Cardiology, also found that triple therapy resulted in more complications.

Patients on a triple therapy regimen are treated with the blood thinner warfarin and two antiplatelet medications. When compared with patients receiving only dual antiplatelet treatment, patients on a triple therapy regimen had the same rates of adverse cardiac events but had a higher incidence of bleeding requiring hospitalization in the two years following discharge.

Using data from the National Cardiovascular Data Registry ACTION Registry-GWTG linked with Centers for Medicare and Medicaid Services data, researchers examined records between January 2007 and December 2010 from nearly 5,000 patients 65 years or older; all patients had a history of atrial fibrillation presenting with a heart attack and being treated with angioplasty and placement of a stent.

During the study period, researchers examined major adverse cardiac events, including death and readmission due to a heart attack or stroke, as well as readmission due to bleeding.

Researchers found that almost 28 percent of patients were discharged on triple therapy compared to 72 percent discharged on dual antiplatelet therapy. Those receiving triple therapy were more likely to be male, have a history of either angioplasty or coronary artery bypass surgery, and have a history of stroke. These patients also were frequently already on warfarin before admission to the hospital. In contrast, patients released on dual antiplatelet therapy were more likely to have had an in-hospital major bleeding event.  

Results showed that after adjusting for patient, treatment, and hospital characteristics, triple therapy was not associated with a lower two-year risk of major adverse cardiac events compared to dual antiplatelet therapy. The risk of bleeding requiring hospitalization within two years after discharge was more than 6 percent higher for patients on triple therapy compared with those on a dual-therapy regimen.    

To verify findings from the primary study, researchers analyzed records from 1,591 Medicare Part D patients and found 93 percent continued to take warfarin 90 days after being discharged from the hospital. The findings from this secondary study were consistent with the results from the primary study: the risk of major adverse cardiac events had not been reduced, and the bleeding risk was higher. 

Connie N. Hess, M.D., M.H.S., the study’s lead author and assistant professor, Department of Medicine, Division of Cardiology at Duke University School of Medicine, and a member of the Duke Clinical Research Institute, said, “The increased risk of bleeding without apparent benefit of triple therapy observed in this study suggests that clinicians should carefully consider the risk-to-benefit ratio of triple therapy use in older atrial fibrillation patients who have had a heart attack treated with angioplasty. Further prospective studies of different combinations of anti-clotting agents are needed to define the optimal treatment regimen for this population.”

In an accompanying editorial, Javier A. Valle, M.D., and John C. Messenger, M.D., both from the Division of Cardiology at the University of Colorado School of Medicine, wrote that while the benefits of triple therapy for preventing major adverse cardiac events remain “troublingly uncertain,” the data are convincing for bleeding. They add that recent investigations have focused on redefining the agents used in triple therapy. Valentin Fuster, M.D., Ph.D., editor-in-chief of the Journal of the American College of Cardiology, acknowledged that the critical question to be answered at present is whether oral anticoagulants plus a single platelet inhibitor – such as clopidogrel – is of a higher benefit-to-risk than triple therapy or dual antiplatelet therapy.    

At this point, however, Valle and Messenger note that “more” does not appear to be “better.” They conclude by asking, “Can we replace ‘more’ with a better alternative?” The answer to date, they say, is “not yet.”

For more information:  www.content.onlinejacc.org

Related Content

PinnacleHealth First in Pennsylvania to Implant Sentinel Cerebral Protection System
News | Embolic Protection Devices| August 23, 2017
PinnacleHealth is the first hospital in Pennsylvania and one of the first 10 in the country to introduce new technology...
Medtronic Announces Global Resolute Onyx DES One-Month DAPT Study
News | Antiplatelet and Anticoagulation Therapies| August 18, 2017
Medtronic plc announced a global randomized clinical trial that will evaluate one-month dual antiplatelet therapy (DAPT...
Bivalirudin exhibited an improvement in 30-day all-cause mortality when injected post PCI.
News | Antiplatelet and Anticoagulation Therapies| August 16, 2017
August 16, 2017 — A study has examined the efficacies of various post-percutaneous coronary intervention (PCI) bivali
CMS considers eliminating cardiac bundled payments.
Feature | Business| August 16, 2017 | Dave Fornell
August 16, 2017 — The Centers for Medicare and Medicaid Services (CMS) announced a proposed rule to reduce the number
ESC 2017 late breaking trial hot line study presentations.
News | Clinical Study| August 16, 2017
Aug. 16, 2017 – The European Society of Cardiology (ESC) Congress 2017 includes several Hot Line Late-breaking Clinic
News | Drug-Eluting Balloons| August 15, 2017
Surmodics Inc. announced receipt of an investigational device exemption (IDE) from the U.S. Food and Drug...
The Vascular Dynamics MobiusHD device enhances the carotid baroreceptors to reduce resistant hypertension.
News | Hypertension| August 15, 2017
Aug. 15, 2017 — The U.S. Food and Drug Administration (FDA) has approved the Vascular Dynamics Inc.
Abbott Initiates First Clinical Trial of Clip-Based Tricuspid Repair System
News | Heart Valve Technology| August 09, 2017
Abbott announced that the first patient has been enrolled in a clinical study to evaluate a minimally invasive clip-...
Overlay Init