[Anticoagulants and dual antiplatelet therapy combined, a challenge to our intelligence].

The combination of antiplatelet and anticoagulant drugs, a common practice in the setting of acute coronary syndromes, constitutes an important practical problem involving difficult decisions, that lack support both in terms of clinical evidence (adequate clinical studies are not available) and strong guidelines. The problem was particularly aggravated from the moment when practically all the patients with acute coronary syndromes started to be submitted to double antiplatelet therapy, especially those treated with drug eluting stents. Simply reminding that 10% of these patients have or will have atrial fibrillation gives us the dimension of the problem. In this paper we discuss the benefits and risks of an eventual triple therapy and present the data obtained from the scarce evidence at our disposal, both from clinical studies and registries. The evidence about the combination of the double antiplatelet therapy with the new anticoagulants is derived from the phase II and phase III studies, conducted with dabigatran, apixaban, darexaban and rivaroxaban. The results from the only phase III study concluded with good results, the ATLAS-ACS 2 TIMI 51 study, conducted with rivaroxaban, are presented. The author also presents some of the recommendations extracted from the consensus document published on this matter by the Working Group on Thrombosis of the European Society of Cardiology.