title: Triple Antithrombotic Therapy With Aspirin, P2Y12 Inhibitor, and Warfarin After Percutaneous Coronary Intervention: An Evaluation of Prasugrel or Ticagrelor Versus Clopidogrel.
abstract: BACKGROUND
  Triple antithrombotic therapy is used in patients who require systemic anticoagulation and undergo percutaneous coronary intervention (PCI) requiring dual antiplatelet therapy. Bleeding with this combination is significant; however, few studies have described outcomes with the use of newer oral P2Y12inhibitors in this setting.
  
  
  OBJECTIVE
  We aimed to compare outcomes among patients prescribed triple therapy with prasugrel or ticagrelor compared to triple therapy with clopidogrel in patients who underwent PCI and required warfarin.
  
  
  METHODS
  We retrospectively evaluated 168 patients who received either prasugrel (n = 32) or ticagrelor (n = 10) and were matched (1:3) to those who received clopidogrel (n = 126) at the time of discharge from the index PCI visit. Matching was performed based on age ±10 years, sex, and indication for PCI. The primary outcome was the incidence of any bleeding during the 12-month follow-up. We also evaluated major adverse cardiovascular and cerebrovascular events (MACCEs).
  
  
  RESULTS
  Patient baseline characteristics were similar between groups. There was a significant excess of bleeding in patients who received prasugrel or ticagrelor compared to clopidogrel as part of triple therapy (28.6% vs 12.7%; odds ratio, 3.3; 95% confidence interval, 1.38-8.34). No differences were seen between groups in MACCEs.
  
  
  CONCLUSIONS
  The use of prasugrel or ticagrelor as part of triple antithrombotic therapy among patients who underwent PCI and received warfarin was associated with significantly more bleeding compared to patients who received clopidogrel. Therefore, higher potency P2Y12inhibitors should be used cautiously in these patients.
authors.affiliation: 1 Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA, USA.
authors.forename: Nathan J
authors.initials: NJ
authors.lastname: Verlinden
authors.affiliation: 2 Department of Pharmacy, UPMC Presbyterian University Hospital, Pittsburgh, PA, USA.|3 Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.
authors.forename: James C
authors.initials: JC
authors.lastname: Coons
authors.affiliation: 3 Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.
authors.forename: Carlo J
authors.initials: CJ
authors.lastname: Iasella
authors.affiliation: 3 Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA.|4 Department of Critical Care Medicine, Clinical Translational Science Institute, Pittsburgh, PA, USA.
authors.forename: Sandra L
authors.initials: SL
authors.lastname: Kane-Gill
mesh_terms: D000241:Adenosine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D000368:Aged; D001241:Aspirin / Q000008:administration & dosage* / Q000009:adverse effects; D015331:Cohort Studies; D004359:Drug Therapy, Combination; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000175:diagnosis; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000639:trends*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D000068799:Prasugrel Hydrochloride / Q000008:administration & dosage* / Q000009:adverse effects; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage* / Q000009:adverse effects; D012189:Retrospective Studies; D000077486:Ticagrelor; D014859:Warfarin / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D014859:Warfarin; D000068799:Prasugrel Hydrochloride; D000077486:Ticagrelor; D000241:Adenosine; D001241:Aspirin
keywords: anticoagulant; antiplatelet; bleeding; percutaneous coronary intervention; triple therapy