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Multiple Antithrombotics Anticoagulants
💡 Key Point: The risk of major bleeding increases substantially when antiplatelet and anticoagulant therapies are combined. Dual and triple therapy should therefore be reserved for clear indications, with regular review of duration and necessity.
🩸 Annual Bleeding Risk by Antithrombotic Regimen
| Regimen | Typical Indication | Bleeding Admission Rate per Year |
|---|---|---|
| 💊 Aspirin | Ischaemic heart disease (IHD), stroke prevention, vascular risk | 2.6% |
| 💊 Clopidogrel | Secondary prevention after stroke or acute coronary syndrome (ACS) | 4.6% |
| 💉 Warfarin | Atrial fibrillation (AF), venous thromboembolism (VTE), antiphospholipid syndrome (APL) | 4.3% |
| 💊 Aspirin + Clopidogrel | Post-stent (PCI), dual antiplatelet therapy (DAPT) after ACS | 3.7% |
| 💊 Aspirin + Warfarin | IHD + VTE, mechanical valve, or AF overlap | 5.1% |
| 💊 Clopidogrel + Warfarin | VTE or mechanical valve with concurrent vascular event | 12.3% ⚠️ |
| 💊 Aspirin + Clopidogrel + Warfarin | Triple therapy (e.g. stent + AF + mechanical valve) | 12% ⚠️ |
🩺 Teaching Commentary
- 🔸 Triple therapy carries a bleeding risk approaching 1 in 8 per year — this is only justified when the thrombotic risk is extreme (e.g., recent stent in a patient with AF and mechanical valve).
- 🔹 Use the shortest effective duration — typically ≤1 month triple therapy, then step down to dual therapy (per ESC 2023).
- 🔸 Consider proton pump inhibitor (PPI) prophylaxis and review for deprescribing opportunities after the acute indication passes.
- 🔹 Always reassess renal function, liver function, and drug interactions, especially with DOAC or warfarin use.
- 🧮 HAS-BLED and CHA₂DS₂-VASc remain key risk–benefit tools in clinical decision-making.
📚 References
- Guidelines on Oral Anticoagulation with Warfarin (BCSH, 2011)
- ESC Antithrombotic Therapy Guidelines (2023) – Dual/Triple Therapy After PCI in AF
- NICE NG196: Atrial Fibrillation: Diagnosis and Management (2021)
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