Heart intertwined with blood vessels, balancing dual and triple antithrombotic therapy.

Navigating Blood Clot Risks: Is Dual Therapy the New Standard After Heart Intervention?

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Mira Elwood in Health & Wellness December 2025 • 5 min read.

"Experts weigh in on balancing bleeding risks and stent thrombosis in atrial fibrillation patients undergoing PCI, advocating for a tailored approach to antiplatelet therapy."


When patients with atrial fibrillation require percutaneous coronary intervention (PCI), clinicians face a complex decision: how to balance the need to prevent blood clots with the risk of bleeding. Traditionally, triple antithrombotic therapy (TAT), which combines antiplatelet drugs and anticoagulants, has been the standard approach. However, recent research suggests that dual antithrombotic therapy (DAT), involving fewer medications, may offer a safer alternative for many patients.

A pivotal commentary published in the European Heart Journal sparked a debate on the optimal antithrombotic strategy. F. Gragnano et al. questioned whether the duration and composition of TAT were the primary drivers of excess bleeding events observed in patients with atrial fibrillation undergoing coronary intervention. This article delves into the expert responses, exploring the nuances of balancing thrombotic and bleeding risks in this vulnerable patient population.

In response to Gragnano's commentary, Harsh Golwala, Christopher P. Cannon, and Deepak L. Bhatt emphasized that while prolonged TAT increases bleeding risk, abbreviating its duration might not provide complete protection. They point to data from the WOEST and ISAR-TRIPLE trials, illustrating that bleeding events can occur even with shorter TAT durations. The discussion highlights the need for personalized treatment strategies that consider individual patient characteristics and risk profiles.

Decoding the Debate: Dual vs. Triple Therapy

Heart intertwined with blood vessels, balancing dual and triple antithrombotic therapy.

The central question revolves around whether dual antithrombotic therapy (DAT) can effectively prevent stent thrombosis (ST) without increasing the risk of bleeding compared to triple antithrombotic therapy (TAT). While TAT has been the conventional approach, it exposes patients to a higher risk of bleeding complications. DAT, on the other hand, aims to minimize bleeding risk by reducing the number of antithrombotic agents used.

Several factors contribute to the complexity of this decision. The duration of TAT, the specific antiplatelet and anticoagulant agents used, and the individual patient's risk factors all play a role. Clinical trials like WOEST and ISAR-TRIPLE have provided valuable insights, but their findings are not always directly applicable to every patient. As such, clinicians must carefully weigh the potential benefits and risks of each strategy.

  • WOEST Trial: Demonstrated that dual antithrombotic therapy (DAT) can reduce bleeding events compared to triple antithrombotic therapy (TAT).
  • ISAR-TRIPLE Trial: Showed that even a shorter duration of TAT (6 weeks) can lead to a significant number of bleeding events.
  • RE-DUAL PCI Trial: Investigated the use of dabigatran, an anticoagulant, in combination with antiplatelet therapy, suggesting potential benefits in reducing bleeding risk.
  • MASTER DAPT, ENTRUST AF-PCI, and AUGUSTUS Trials: Ongoing trials may provide further insights into optimizing antithrombotic strategies in patients with atrial fibrillation undergoing PCI.
One concern raised by Gragnano et al. was the potential for increased stent thrombosis (ST) with DAT. However, the authors of the response clarify that their analysis did not demonstrate a statistically significant difference in ST rates between DAT and TAT. Furthermore, they note that the inclusion of both doses of dabigatran (110mg and 150mg b.i.d.) in the RE-DUAL trial may have influenced the results, as a more detailed analysis focusing on dabigatran 150mg b.i.d. showed no difference in ST rates.

The Path Forward: Personalized Antithrombotic Strategies

While ongoing clinical trials like MASTER DAPT, ENTRUST AF-PCI, and AUGUSTUS may provide further clarity, the experts advocate for a personalized approach to antithrombotic therapy. In most patients with atrial fibrillation undergoing PCI, discharge on DAT should be the default strategy. Individual patient factors, such as bleeding risk, thrombotic risk, and the specific clinical context, should guide the choice between DAT and TAT. By carefully assessing these factors, clinicians can optimize antithrombotic strategies to improve outcomes and minimize complications in this complex patient population.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

Everything You Need To Know

1

What is the primary challenge when treating atrial fibrillation patients undergoing percutaneous coronary intervention (PCI)?

The primary challenge is balancing the need to prevent blood clots with the risk of bleeding. Clinicians must choose the optimal antithrombotic strategy, considering factors such as the patient's risk of stent thrombosis (ST) and bleeding, the duration of treatment, and the specific medications used. This involves a careful assessment of individual patient characteristics and risk profiles, as the ideal approach varies from person to person.

2

What are the differences between dual antithrombotic therapy (DAT) and triple antithrombotic therapy (TAT), and what are their implications?

DAT involves fewer medications, typically antiplatelet drugs, aiming to minimize bleeding risk compared to TAT, which combines antiplatelet drugs and anticoagulants. TAT has traditionally been the standard approach, but it exposes patients to a higher risk of bleeding complications. DAT aims to minimize this risk. The choice between them depends on the individual patient's bleeding and thrombotic risk profiles. Trials like WOEST and ISAR-TRIPLE have provided insights, and ongoing trials like MASTER DAPT, ENTRUST AF-PCI, and AUGUSTUS are expected to further clarify the optimal antithrombotic strategies.

3

How do trials like WOEST and ISAR-TRIPLE influence the decision to use dual antithrombotic therapy (DAT) or triple antithrombotic therapy (TAT)?

The WOEST trial showed DAT can reduce bleeding events compared to TAT. The ISAR-TRIPLE trial showed that even short-term TAT can lead to bleeding events. These findings suggest that while TAT may provide stronger protection against blood clots, it comes with an increased risk of bleeding. As a result, these trials contribute to the debate about the duration and composition of TAT, advocating for a personalized approach. The trials' outcomes are not always directly applicable to every patient, and it underscores the need for a tailored strategy based on individual patient characteristics and risk profiles.

4

What role does stent thrombosis (ST) play in the choice between dual antithrombotic therapy (DAT) and triple antithrombotic therapy (TAT)?

A key concern is the potential for increased ST with DAT. However, analysis has not demonstrated a statistically significant difference in ST rates between DAT and TAT. The choice between DAT and TAT needs careful consideration. Clinicians weigh the risk of ST against the risk of bleeding, considering the individual patient's profile. They need to assess whether the increased bleeding risk of TAT outweighs the potential benefit of preventing ST.

5

What is the recommended approach to antithrombotic therapy for atrial fibrillation patients undergoing PCI, and why?

The experts advocate for a personalized approach. In most patients with atrial fibrillation undergoing PCI, discharge on DAT should be the default strategy. This is because DAT aims to reduce bleeding risk. The choice between DAT and TAT should be guided by individual patient factors, such as bleeding risk, thrombotic risk, and the specific clinical context. Clinical trials like MASTER DAPT, ENTRUST AF-PCI, and AUGUSTUS may provide further clarity. By carefully assessing these factors, clinicians can optimize antithrombotic strategies to improve outcomes and minimize complications in this complex patient population.

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