Major
clopidogrel × warfarin
Antiplatelet agents – P2Y12 receptor inhibitors×Vitamin K antagonist anticoagulants
Mechanism
Additive antithrombotic effect: warfarin in the coagulation cascade plus clopidogrel at the platelet P2Y12 receptor. Major bleeding risk rises 2.5–3-fold.
Management
Triple therapy (warfarin + aspirin + clopidogrel) after stenting in AF patients is limited to about 1 month, then transitioned to dual therapy (warfarin + clopidogrel or aspirin) for 6–12 months. After one year, warfarin alone. An alternative is the WOEST/PIONEER regimen with a DOAC (apixaban) + clopidogrel.
Sources
- AUGUSTUS Investigators: Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation (2019)— N Engl J Med 2019;380(16):1509–1524
- ESC: 2023 ESC Guidelines for the management of acute coronary syndromes (2023)— Eur Heart J 2023;44(38):3720–3826
- ESC: 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the EACTS (2024)— Eur Heart J 2024;45(36):3314–3414