World Journal of Surgery

, Volume 41, Issue 2, pp 423–432 | Cite as

Triple Antithrombotic Therapy and Outcomes in Post-PCI Patients Undergoing Non-cardiac Surgery

  • Javier A. Valle
  • Laura Graham
  • Aerin DeRussy
  • Kamal Itani
  • Mary T. Hawn
  • Thomas M. Maddox
Original Scientific Report



Triple therapy, or the use of anticoagulants with dual antiplatelet therapy (DAPT), is often used to protect against ischemic events in post-percutaneous coronary intervention (PCI) patients with indications for anticoagulation, but is associated with increased bleeding. As both ischemic and bleeding risks increase in the perioperative period, the impact of triple therapy may be especially pronounced in patients undergoing surgery. Outcomes in this population are currently unknown.


We identified patients undergoing non-cardiac surgeries within 2 years of PCI in Veterans Affairs hospitals from 2004 to 2012. We compared perioperative major adverse cardiovascular and cerebrovascular events (MACCE: mortality, myocardial infarction, stroke, revascularization) and bleeding events (in-hospital bleeding, transfusion) between surgeries in patients prescribed triple therapy and DAPT, adjusting for clinical, demographic, and operative characteristics.


Among 7811 surgeries, 391 (5.0 %) occurred in patients receiving triple therapy. 44 (11.3 %) MACCE and 107 (27.4 %) bleeding events occurred with surgeries in triple therapy patients, compared to 366 (4.9 %) MACCE and 980 (13.2 %) bleeding events in DAPT patients. After adjustment, surgery in triple therapy patients was associated with higher rates of MACCE [odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.16–2.34] or bleeding (OR 1.52, 95 % CI 1.17–1.99) as compared to surgery in DAPT patients.


One in twenty post-PCI patients undergoing non-cardiac surgery were on triple therapy. Surgery in these patients was associated with higher MACCE and bleeding events compared to surgery in patients on DAPT, independent of clinical and operative characteristics. These findings identify a high-risk population for surgery, which may warrant increased surveillance for adverse perioperative events.


Clopidogrel Triple Therapy Bleeding Event Prasugrel Ticagrelor 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



There are no relationships with industry to disclose. Dr. Valle is supported by a NIH T32 training Grant HL0782 at the University of Colorado, Aurora, CO.

Supplementary material

268_2016_3725_MOESM1_ESM.docx (89 kb)
Supplementary material 1 (DOCX 89 kb)


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Copyright information

© Société Internationale de Chirurgie 2016

Authors and Affiliations

  • Javier A. Valle
    • 1
    • 5
  • Laura Graham
    • 2
  • Aerin DeRussy
    • 2
  • Kamal Itani
    • 3
  • Mary T. Hawn
    • 4
  • Thomas M. Maddox
    • 1
  1. 1.VA Eastern Colorado Health Care SystemUniversity of Colorado School of MedicineDenverUSA
  2. 2.Birmingham Veterans Affairs Medical CenterBirminghamUSA
  3. 3.Veterans Affairs Boston Health Care SystemBoston University and Harvard Medical SchoolBostonUSA
  4. 4.Stanford University School of MedicinePalo AltoUSA
  5. 5.Division of CardiologyUniversity of Colorado HospitalAuroraUSA

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