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Triple Therapy Duration After PCI in AF — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyTriple Therapy Duration After PCI in AFEECC

A 55-year-old man with AF and stable CAD (prior PCI 2 years ago, on aspirin and clopidogrel) is started on apixaban for AF. He is now on triple therapy (aspirin + clopidogrel + apixaban). For how long should triple therapy continue?

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Correct answer: D — Triple therapy should be as brief as possible — stop aspirin within 1 week (or at most 1 month) and continue dual therapy (OAC + clopidogrel) for 6-12 months, then OAC alone; prolonged triple therapy dramatically increases bleeding without proportional ischaemic benefit

The management of AF patients requiring antiplatelet therapy after PCI has been refined by the WOEST, PIONEER AF-PCI, RE-DUAL PCI, AUGUSTUS, and ENTRUST-AF PCI trials: (1) Periprocedural: triple therapy (OAC + aspirin + P2Y12 — clopidogrel preferred over ticagrelor/prasugrel); (2) EARLY aspirin drop: stop aspirin at 1 week (AUGUSTUS showed aspirin-free dual therapy reduced bleeding by ~50% without increasing stent thrombosis); (3) Dual therapy (OAC + clopidogrel): continue for 6-12 months (shorter for high bleeding risk, longer for high ischaemic risk — recent ACS); (4) Then OAC alone for long-term stroke prevention. This patient at 2 years post-PCI should have aspirin stopped immediately (no longer needed), continue apixaban + clopidogrel short-term, then transition to apixaban alone. The key principle: minimise the duration of multiple antithrombotic agents to reduce bleeding.

Reference: ESC (2024): AF Guidelines; AUGUSTUS Trial