Dual antiplatelet therapy and antithrombotic treatment in patients with acute coronary syndrome--does everyday medical practice reflects current recommendations? A pilot study.

Background: Dual antiplatelet therapy for 12 months is currently recommended for all patients with acute coronary syndrome (ACS), both for those treated pharmacologically or with percutaneous coronary interventions (PCI). Recently, the need for simultaneous administration of dual antiplatelet and oral anticoagulant therapy (triple therapy) has become more common. However, in addition to intensifying antiplatelet treatment, the risk of haemorrhagic complications is also significantly increased with triple therapy.

Aim: To assess the in-hospital use of triple therapy in patients with ACS, who have indications for long-term anticoagulation, and to define the reasons for not administering such a therapy.

Methods: The analysis included 298 patients diagnosed with ACS who were admitted to our department. Analysis of recommended treatment was conducted upon discharge from hospital after ACS and during hospitalisation. The reason for discontinuation or non-compliance with oral anticoagulant (OAC) therapy was also assessed.

Results: Out of 298 patients diagnosed with ACS, 53 (17.8%) had indications for long-term anticoagulation. The largest group consisted of patients with unstable angina who were treated pharmacologically (51.7%). The most common indication for chronic anticoagulation was paroxysmal atrial fibrillation (AF) (62%). At discharge from hospital, only 15.1% of patients received triple therapy. There was no significant association between the mode of treatment (triple therapy vs. lack of it) and indication for antiplatelet treatment (p = 0.18) or anticoagulation (p = 0.27). Among risk factors for bleeding, only prior episode of bleeding [p = 0.0002; odds ratio (OR) 4.17] and treatment with PCI (p = 0.02; OR impossible to assess because of too small group) were significantly associated with withdrawal of triple therapy.

Conclusions: The use of triple therapy in patients presenting with ACS and indications for long-term anticoagulation is insufficient. The reasons for not prescribing triple therapy are not clear. One explanation could be excessive concerns about haemorrhagic complications. There is a lack of equivocal guidelines and large randomised trials which would clearly define the optimal management strategy for patients presenting with ACS and indications for long-term anticoagulation therapy.