The European Society of Cardiology ( ESC ) has published a position paper on the topic of triple therapy that shows great similarity to North American recommendations: diminished intensity of anticoagulation ( international normalized ratio, INR between 2.0 and 2.5 ), use of low-dose Acetylsalicylic acid ( Aspirin ), and avoidance of the use of drug-eluting stents in patients with high bleeding risk.
The strength of the European approach is that a clear and clinically easy differentiation is made between elective stent implantation and procedures in the setting of acute coronary syndromes with and without ST-segment elevation.
In acute coronary syndromes, the thrombus load and thus the thrombotic risk are larger than in stable coronary disease. This is probably true for both the risk of stent thrombosis and the risk of stroke.
These differences argue for a more potent approach in the setting of acute coronary syndromes but not necessarily over the long term.
In Europe, a short course of dual antiplatelet therapy ( 1 month ) in elective stenting with a bare metal stent is advised for patients on oral anticoagulants, whereas American recommendations suggest 1 month of dual antiplatelet therapy followed by single antiplatelet therapy ( Aspirin or Clopidogrel [ Plavix ] ) for 12 months.
In a high-thrombotic-risk situation, American experts advise dual antiplatelet therapy for a full year after drug-eluting stent implantation for patients on oral anticoagulation, whereas the Europeans advise dual antiplatelet therapy for 3 months for the modern limus-eluting stents and 6 months for the Paclitaxel-eluting stents. ( Xagena )
Verheugt FWA, Circulation 2013; 128: 2058-2061