Use of novel oral anticoagulants for secondary prevention after ACS

• Platelet and coagulation factors are both involved in atherothrombosis
• Evidence for acute ACS management supports combination of both classes to reduce acute thrombosis, but data for long term combination of antiplatelet and anticoagulant are less convincing
• Apixaban plus DAPT (clopidogrel) did not reduce vascular events and was associated with increased major, intracranial and fatal bleeding
• Dabigatran plus DAPT (clopidogrel) also increased major bleeding in a small trial not powered to assess reduction in vascular events
• Rivaroxaban at very low dose plus DAPT (clopidogrel) demonstrated a significant vascular and mortality outcome benefit, but increased the risk of major and intracranial bleeding

NOAC plus DAPT for secondary prevention after ACS

We suggest against the use of triple therapy with rivaroxaban, clopidogrel, and ASA over the use of dual therapy with ticagrelor or prasugrel plus ASA for secondary prevention of ACS (Conditional, Very Low).

We recommend against the use of dabigatran and apixaban at any dose in combination with antiplatelet therapy for secondary prevention of ACS (Strong, High).

Values and Preferences

• This recommendation recognizes the significant absolute benefit of triple therapy with rivaroxaban, clopidogrel, and ASA over dual therapy with clopidogrel and ASA for the composite outcome of cardiovascular death, MI, or stroke, and total mortality. However, we remain concerned about increased risk of bleeding complications.
• A similar ischemic benefit has been observed over clopidogrel plus ASA by using DAPT with ASA plus ticagrelor or prasugrel with an apparent lesser increased risk of bleeding over triple therapy with rivaroxaban, clopidogrel, and ASA.
• Our recommendation further recognizes the increased complexity and cost of taking three medications over two.

Practical tips

• There might be patients in whom combining an oral anticoagulant with DAPT is warranted, such as patients with atrial fibrillation or a mechanical heart valve who develop ACS. Attention is needed to monitor and minimize the duration of \"triple antithrombotic therapy\" considering the high risk for bleeding associated with such treatment.