Journal of Thrombosis and Thrombolysis

, Volume 38, Issue 3, pp 285–298 | Cite as

Dual antiplatelet therapy with or without oral anticoagulation in the postdischarge management of acute coronary syndrome patients with an indication for long term anticoagulation: a systematic review

  • Jeffrey B. Washam
  • Rowena J. Dolor
  • W. Schuyler Jones
  • Sharif A. Halim
  • Victor Hasselblad
  • Stephanie B. Mayer
  • Brooke L. Heidenfelder
  • Chiara Melloni


Currently, there is a lack of consensus among guidelines for the postdischarge treatment of patients presenting with acute coronary syndrome (ACS) who have a long-term indication for anticoagulation. We conducted a systematic review comparing the safety and effectiveness of dual antiplatelet therapy (DAPT) and triple therapy (TT; defined as DAPT plus an oral anticoagulant) in patients with ACS and a long-term indication for anticoagulation. We searched for clinical studies in MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews published between January 1995 and September 2013. Each investigator screened and abstracted data, assessed applicability and quality, and graded the strength of evidence. Meta-analysis of direct comparison was performed when outcomes and follow-up periods were comparable. Fourteen observational studies were identified that contained comparative effectiveness data on DAPT versus TT. No difference in the odds of mortality (OR 1.04, 95 % CI 0.59–1.83) or stroke (OR 1.01, 95 % CI 0.38–2.67) at 1–5 years was found between TT and DAPT. Major bleeding at 1–5 years (OR 1.46, 95 % CI 1.07–2.00) and nonfatal MI at 1–5 years (OR 1.85, 95 % CI 1.13–3.02) occurred more frequently in patients receiving TT. The results of this systematic review demonstrate that treatment with TT was associated with increased rates of nonfatal MI and major bleeding when compared with treatment with DAPT in the postdischarge management of ACS patients with an indication for oral anticoagulation. Until results of ongoing randomized trials assessing antithrombotic therapies define optimal management strategies, the current analysis suggests using caution when prescribing TT to these patients.


Triple therapy Dual antiplatelet therapy Acute coronary syndrome 



The authors thank Megan von Isenburg, MSLS, for help with the literature search and retrieval; Megan M. Chobot, MSLS, for project coordination; and Liz Wing, MA, for editorial assistance. This Project was funded under Contract No. 290-2007-10066-I from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. The authors of this manuscript are responsible for its content. Statements in the manuscript should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Conflict of Interest

The authors declare that they have no conflict of interest.


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Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Jeffrey B. Washam
    • 1
  • Rowena J. Dolor
    • 2
  • W. Schuyler Jones
    • 2
  • Sharif A. Halim
    • 2
  • Victor Hasselblad
    • 2
  • Stephanie B. Mayer
    • 3
  • Brooke L. Heidenfelder
    • 2
  • Chiara Melloni
    • 2
  1. 1.Duke Heart CenterDuke University Medical CenterDurhamUSA
  2. 2.Duke Clinical Research InstituteDuke University Medical CenterDurhamUSA
  3. 3.Division of Endocrinology and Metabolism, Department of MedicineVirginia Commonwealth UniversityRichmondUSA

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