Background: Patients with acute coronary syndromes (ACS) and a history of atrial fibrillation
(AF) have indications for both dual antiplatelet therapy (DAPT) and oral anticoagulation
(OAC). Triple therapy (TT), the combination of DAPT and OAC, is recommended in guidelines.
We examined studies comparing clinical outcomes on DAPT versus TT for patients with AF and
Methods: We searched Medline, Medline pending, EMBASE and Evidence-Based Medicine Reviews
databases for studies published between January 2000 to December 2016 in AF patients with
ACS that compared DAPT and TT that reported ischaemic and/or bleeding outcomes. Studies that
were not purely an AF population were excluded.
Results: Ten studies were included in the review, all of which were observational, 8 of which were
retrospective. None of the studies detailed the specifics of treatment allocation. All but one were of
AF patients with a mix of stable coronary disease and ACS patients. TT was associated with increased
bleeding when compared to DAPT, with adjusted odds ratios ranging from 1.25 to 6.84.
While the largest study reported a reduction in stroke associated with TT (odds ratio 0.67), two
other studies reported non-significant increases in stroke with TT. Variable composite ischaemic
endpoints were reported, none showing a statistical significant difference between DAPT and TT.
Conclusion: In patients with ACS and AF, TT is likely to be associated with increased risk of
bleeding, without a clear reduction in ischaemic endpoints. The quality of the evidence to support
current guidelines for this patient group was generally poor.