Combination Antiplatelet and Anticoagulant Therapy

Key points

• Patients increasingly have an indication for BOTH an antiplatelet (established cardiovascular disease) and an anticoagulant (AF, VTE or valvular disease). Combination therapy raises bleeding risk substantially and is often unnecessary.
• Stable cardiovascular disease with an indication for anticoagulation (e.g. AF): give ANTICOAGULANT MONOTHERAPY and stop the antiplatelet · stroke risk guided by CHA2DS2-VASc.
• After ACS or PCI in someone needing an anticoagulant: short triple therapy (aspirin + P2Y12 inhibitor + anticoagulant), kept as brief as bleeding risk allows, then dual therapy (a P2Y12 inhibitor plus the anticoagulant) to complete about 12 months, then anticoagulant alone · clopidogrel is the preferred P2Y12 inhibitor in this setting.
• Assess bleeding risk with the ORBIT score — NICE NG196 replaced HAS-BLED because ORBIT predicted absolute bleeding risk more accurately. Bleeding risk is a prompt to modify reversible factors, not a reason to withhold anticoagulation.
• VTE in someone already on an antiplatelet: anticoagulate for at least 3 months · review whether the antiplatelet is still indicated and stop it if it is not, rather than continuing both by default.
• Modifiable bleeding factors to address in everyone on combination therapy: uncontrolled hypertension · concurrent NSAIDs or SSRIs · harmful alcohol use · poor INR control · anaemia · add a proton pump inhibitor for gastroprotection.

Decision points in this pathway

• Stable cardiovascular disease (no recent ACS or PCI) with an indication for anticoagulation?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.