Perhaps we can drop Aspirin from the mix when you have a stent and are on warfarin before?
In the WOEST trial, 573 patients received either dual therapy with oral anticoagulation and clopidogrel (75 mg daily) or to triple therapy with oral anticoagulation, clopidogrel, and aspirin 80 mg daily. Treatment was continued for one month after bare-metal stenting (35% of patients) and one year after drug-eluting-stent placement (65% of patients). Follow-up was for one year.
There was a significant reduction in minimal and minor bleeding, and while major bleeding was also numerically lower, this did not reach statistical significance (p=0.159).
Perhaps the trial was too small to confirm that stent thrombosis, acute clotting, would not happen.
A registry that has now come out. In a national registry that was not randomised, but had 12,000 patients with atrial fibrillation and a need for warfarin, missing out aspirin appeared to be safe. It is unclear why aspirin was missed out, but it is usually done as the bleeding risk is high, as the fact that this group had lower bleeding is impressive. Warfarin plus clopidogrel may be the new standard of care.
| End point | All-cause mortality | MI/coronary death | Bleeding complications |
| Oral anticoagulation plus aspirin | 1.52 (1.17-1.99)
|
0.96 (0.77-1.19)
|
0.69 (0.53-0.90)
|
| Oral anticoagulation plus clopidogrel | 0.87 (0.56-1.34)
|
0.69 (0.48-1.00)
|
0.78 (0.55-1.12)
|
| Aspirin plus clopidogrel | 1.60 (1.25-2.05) | 1.17 (0.96-1.42) | 0.48 (0.38-0.61) |