Foro Medico Nicaraguense

Por la Instalación del Colegio de Médicos y Cirujanos de Nicaragua

Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010 Sep 13;170(16):1433-41



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BACKGROUND: Patients with atrial fibrillation (AF) often require anticoagulation and platelet inhibition, but data are limited on the
bleeding risk of combination therapy.
METHODS: We performed a cohort study using nationwide registries to identify all Danish patients
surviving first-time hospitalization for AF between January 1, 1997,
and December 31, 2006, and their posthospital therapy of warfarin,
aspirin, clopidogrel, and combinations of these drugs. Cox proportional
hazards models were used to estimate risks of nonfatal and fatal
bleeding.
RESULTS: A total of 82 854 of 118 606 patients (69.9%) surviving AF hospitalization had at least 1 prescription filled for
warfarin, aspirin, or clopidogrel after discharge. During mean (SD)
follow-up of 3.3 (2.6) years, 13 573 patients (11.4%) experienced a
nonfatal or fatal bleeding. The crude incidence rate for bleeding was
highest for dual clopidogrel and warfarin therapy (13.9% per
patient-year) and triple therapy (15.7% per patient-year). Using
warfarin monotherapy as a reference, the hazard ratio (95% confidence
interval) for the combined end point was 0.93 (0.88-0.98) for aspirin,
1.06 (0.87-1.29) for clopidogrel, 1.66 (1.34-2.04) for
aspirin-clopidogrel, 1.83 (1.72-1.96) for warfarin-aspirin, 3.08
(2.32-3.91) for warfarin-clopidogrel, and 3.70 (2.89-4.76) for
warfarin-aspirin-clopidogrel.
CONCLUSIONS: In patients with AF, all combinations of warfarin, aspirin, and clopidogrel are associated with
increased risk of nonfatal and fatal bleeding. Dual warfarin and
clopidogrel therapy and triple therapy carried a more than 3-fold
higher risk than did warfarin monotherapy.

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