Triple Oral Antithrombotic Therapy in Atrial Fibrillation and Coronary Artery Stenting


  • Christopher P. Cannon, MD, has received research grants/support from the following companies: Accumetrics, AstraZeneca, CSL Behring, Essentialis, GlaxoSmithKline, Merck, Regeneron, Sanofi Takeda; has been on the advisory boards (funds donated to charity) of the following companies: Alnylam, Bristol-Myers Squibb, Lipimedix, Pfizer; and has been clinical advisor, equity, for Automedics Medical Systems.

  • The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Address for correspondence: Grant W. Reed, MD Department of Cardiovascular Medicine The Cleveland Clinic 9500 Euclid Avenue, Desk J3-6 Cleveland, OH 44195


Patients with atrial fibrillation affected by an acute coronary syndrome have indications for oral anticoagulation and dual antiplatelet therapy with aspirin and a P2Y12 adenosine diphosphate receptor inhibitor after coronary artery stenting. The concurrent use of all 3 agents, termed triple oral antithrombotic therapy, significantly increases the risk of bleeding. To date, there is a lack of evidence on the proper combination and duration of anticoagulant and antiplatelet agents in patients with indications for both therapies. As such, care has been guided by expert opinion, and there is wide variation in clinician practice. In this review, the latest evidence on the risks and benefits of triple oral antithrombotic therapy in patients with atrial fibrillation after coronary artery stenting is summarized. We discuss the clinical risk scores useful in guiding the prediction of stroke, bleeding, and stent thrombosis. Additionally, we highlight where additional evidence is needed to determine the proper balance of anticoagulant and antiplatelet agents in this patient population.