The role of triple antithrombotic therapy in patients with atrial fibrillation and coronary stent insertion

Triple antithrombotic therapy or 'triple therapy' describes the combination of 3 oral antithrombotic medications - an anticoagulant drug (warfarin, apixaban, rivaroxaban or dabigatran) and 2 antiplatelet drugs (usually aspirin plus clopidogrel). Most commonly, triple therapy is indicated for patients who require both dual antiplatelet therapy following coronary stent insertion for acute coronary syndrome and long-term anticoagulation for atrial fibrillation. Current evidence supports shorter durations of triple therapy to mitigate bleeding risks without compromising ischaemic protection. Recent guidelines advocate up to 1 week of triple therapy for most patients, extending up to 1 month for those at high ischaemic risk. In practice, the approach to antithrombotic therapy is individualised by the patient's cardiologist, balancing bleeding and ischaemic risks. General practitioners and pharmacists have an important role in supporting patients in their step-down plan to dual therapy with the oral anticoagulant drug and one of the antiplatelet drugs, and then ongoing monotherapy with the oral anticoagulant drug.