This Figure presents one of the decision algorithm for antithrombotic therapy in patients with AFib who have received a stent post-PCI.  The issue should be whether a patient is at a high risk of having a stroke with a CHADS2 score ≥2, which mandates starting an antithrombin agent.  In this case the patient’s CHADS2 score was simply >1.  This means it is time to use the CHA2DS2-VASc score and fine-tune whether the patient is really at increased risk of a stroke.  If the patient really is at high risk of bleeding, then obviously the physician should try to get by with just dual antiplatelet therapy and avoid using an antithrombin agent in conjunction with the triple therapy.  If, however, the CHA2DS2-VASc calculation reveals a lower risk of bleeding (i.e., not a high risk of bleeding), then triple therapy including an antithrombin agent is indicated.

So this patient, who was thought to not have a high risk of bleeding, was placed on triple therapy with the caveat that he was also given two bare-metal stents, and as a result one could stop the antiplatelet clopidogrel after just 1 month while trying to maintain the antithrombin warfarin at an INR level in the low therapeutic range.

There are many nuances here, and all this information has not been studied exhaustively, so there is not yet a full database to indicate whether one therapy or one way of treating patients is more appropriate than another.

French WJ. Am J Med 2013; 126: 00-00.