title: Concomitant use of warfarin and ticagrelor as an alternative to triple antithrombotic therapy after an acute coronary syndrome.
abstract: BACKGROUND
  Treatment with warfarin in combination with clopidogrel has been shown to reduce the incidence of major bleeding as compared to triple antithrombotic therapy (TT; warfarin, clopidogrel and aspirin). However, there are uncertainties regarding the risk for thrombosis since poor-responsiveness to clopidogrel is common. Ticagrelor is a more potent platelet inhibitor, but data supporting concurrent use of ticagrelor and warfarin (dual antithrombotic therapy, DT) is limited. This study therefore sought to evaluate the risk of bleeding and thrombosis associated with DT after an acute coronary syndrome (ACS).
  
  
  METHODS
  We identified all ACS patients on DT upon discharge from Helsingborg Hospital and Skåne University Hospital in Malmö and Lund, Sweden, during 2013. Patients on DT were compared with historical controls discharged with TT. Major bleeding was defined in accordance with the HAS-BLED derivation study. Patients were retrospectively followed for three months.
  
  
  RESULTS
  In total, 107 DT patients were identified and compared with 159 controls on TT. Mean HAS-BLED bleeding risk score and duration of treatment were similar between the groups (HAS-BLED 2.2+/-0.8 vs 2.2+/-1.0 units, p=NS; duration 2.7+/-0.8 vs 2.5+/-0.9months, p=NS; DT vs TT). The incidence of spontaneous major bleeding was similar between the groups, as was a composite of all thrombotic events, i.e. peripheral embolism, stroke/TIA and acute coronary syndrome (bleeding 8/106 (7.5%) vs 11/157 (7.0%), p=NS; thrombosis 5/106 (4.7%) vs 5/157 (3.2%), p=NS; DT vs TT).
  
  
  CONCLUSIONS
  Rates of thrombotic and bleeding events were similar in patients with TT and patients with ticagrelor and warfarin.
authors.affiliation: Department of Cardiology, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: oscar.braun@med.lu.se.
authors.forename: Oscar Ö
authors.initials: OÖ
authors.lastname: Braun
authors.affiliation: Department of Cardiology, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: besim.bico@med.lu.se.
authors.forename: Besim
authors.initials: B
authors.lastname: Bico
authors.affiliation: Department of Internal Medicine, Helsingborg Hospital, Lund University, Lund and Helsingborg, Sweden. Electronic address: uzma9c@hotmail.com.
authors.forename: Uzma
authors.initials: U
authors.lastname: Chaudhry
authors.affiliation: Department of Internal Medicine, Helsingborg Hospital, Lund University, Lund and Helsingborg, Sweden. Electronic address: henrik.wagner@med.lu.se.
authors.forename: Henrik
authors.initials: H
authors.lastname: Wagner
authors.affiliation: Department of Cardiology, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: sasha.koul@med.lu.se.
authors.forename: Sasha
authors.initials: S
authors.lastname: Koul
authors.affiliation: Department of Cardiology, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: patrik.tyden@skane.se.
authors.forename: Patrik
authors.initials: P
authors.lastname: Tydén
authors.affiliation: Department of Cardiology, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: fredrik.schersten@skane.se.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Scherstén
authors.affiliation: Department of Cardiology, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: stefan.jovinge@med.lu.se.
authors.forename: Stefan
authors.initials: S
authors.lastname: Jovinge
authors.affiliation: Department for Coagulation Disorders, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: peter.svensson@med.lu.se.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Svensson
authors.affiliation: Department of Cardiology, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: gustav.smith@med.lu.se.
authors.forename: J
authors.initials: J
authors.lastname: Gustav Smith
authors.affiliation: Department of Cardiology, Skåne University Hospital, Lund University, Lund and Malmö, Sweden. Electronic address: jesper.vanderpals@med.lu.se.
authors.forename: Jesper
authors.initials: J
authors.lastname: van der Pals
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood / Q000188:drug therapy*; D000241:Adenosine / Q000008:administration & dosage / Q000031:analogs & derivatives*; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000008:administration & dosage; D001281:Atrial Fibrillation / Q000188:drug therapy; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006470:Hemorrhage; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013927:Thrombosis / Q000503:physiopathology; D000077486:Ticagrelor; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives; D016896:Treatment Outcome; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D005343:Fibrinolytic Agents; D014859:Warfarin; D000077144:Clopidogrel; D000077486:Ticagrelor; D000241:Adenosine; D013988:Ticlopidine; D001241:Aspirin
keywords: Acute coronary syndrome; Antithrombotic therapy; Ticagrelor; Warfarin