Combined oral anticoagulants and antiplatelets: benefits and risks

Abstract

Combined antiplatelet and anticoagulant therapy has been suggested for those clinical conditions in which conventional antithrombotic regimens have shown suboptimal efficacy, and in patients with indication for both: antiplatelet and anticoagulant therapy. Clinical trials aimed at assessing the clinical benefit of the association with respect to mono-therapy have been conducted in patients with atrial fibrillation, in patients with recent myocardial infarction, and in patients with prosthetic heart valves. Overall, a favorable benefit-risk profile of combined therapy in comparison to anticoagulant alone has been observed in patients with mechanical prosthetic heart valves and in those with coronary artery disease while no clear advantage has been shown in patients with atrial fibrillation. In almost all these studies, however, a higher risk of major bleeding has been observed in patients receiving combined therapy in comparison to patients receiving warfarin alone. Thus, a combined regimen of anticoagulant and antiplatelet therapy should be reserved for selected patients at high risk of thromboembolic events who have a low risk of bleeding.

Effect of concomitant antiplatelet therapy in patients with nonvalvular atrial fibrillation initiating non‐vitamin K antagonists

“…4 Coronary artery disease and peripheral artery disease are frequent comorbidities in AF patients, with a documented prevalence that ranges from 18% to 45% and 4%-17%, respectively. [9][10][11][12][13][14][15] These patients are at high risk for stroke, myocardial infarction and cardiovascular death, [16][17][18][19] and that often leads to prescription of concomitant antiplatelet therapy in addition to OAC. However, several previous studies have shown a higher risk of bleeding 20,21 without a risk reduction in ischaemic events with OAC plus antiplatelet combination vs OAC monotherapy.…”

Epistaxis in patients taking oral anticoagulant and antiplatelet medication: prospective cohort study

“…1 In the majority of cases, the cause of epistaxis is unknown. 3 Patients taking these medications form an important subgroup of epistaxis cases, as they are potentially more difficult to manage in the emergency department and have higher rates of co-morbidity (e.g. These systemic factors include oral anticoagulant medication (e.g.…”

Combined oral anticoagulant and antiplatelet treatment: need for an evidence-based approach

“…In conclusion, the review by Vedovati et al [1] will be certainly useful for the physician in order to reconsider his trend in prescribing combined anticoagulant-antiplatelet treatment. I hope that caution will be used in daily clinical practice: we should be aware that a serious bleeding event requires the interruption of any anticoagulant and antiplatelet drug (sometimes for long periods), exposing the patient to the subsequent high risk of thromboembolic/ ischemic events.…”

“…Indications and contra-indication should be periodically reconsidered in each patient on combined treatment. Vedovati et al [1] of the combined treatment has been demonstrated in patients with atrial fibrillation, which is by far the most frequent indication for VKA. Phase III trials investigating new anticoagulants such as idraparinux [2] and ximelagatran [3,4] also provide evidence about the increased risk of bleeding due to combined VKA-aspirin treatment in patients with atrial fibrillation.…”

“…Sometimes it may be difficult to assess the benefit-risk profile of combined anticoagulant-antiplatelet treatment versus the use of a single antithrombotic agent. For the above-mentioned reasons, the excellent review by Vedovati et al [1], published in this issue of Internal and Emergency Medicine, can be very helpful in clinical practice. The authors made an extensive and critical perusal of the available studies and come to well documented, sound conclusions.…”