When More Medication Isn't Necessarily Better

Atrial fibrillation patients who had undergone angioplasty didn't have better outcomes with triple therapy

/ Author:  / Reviewed by: Joseph V. Madia, MD Beth Bolt, RPh

(RxWiki News) More isn't always better, and that may be especially true when it comes to heart attack medications.

A new study from Duke University found that, for patients who had atrial fibrillation after a heart attack that was treated with an angioplasty, additional medication increased the risk of bleeding and didn't prevent more heart problems.

"The increased risk of bleeding without apparent benefit of triple therapy observed in this study suggests that clinicians should carefully consider the risk-to-benefit ratio of triple therapy use in older atrial fibrillation patients who have had a heart attack treated with angioplasty," said lead study author Connie N. Hess, MD, a professor of cardiology at Duke University School of Medicine, in a press release.

Jeffrey M. Schussler, MD, of Baylor Heart and Vascular Hospital and Baylor University Medical Center at Dallas, TX, told dailyRx News that, "When we put stents in the heart, it's absolutely important to be on anti-platelet therapy. However, patients sometimes have other issues (AF, mechanical heart valves) which should be treated with additional other anti-coagulants. We know that there is not a 'one-size-fits-all' treatment plan for these complicated patients, and it appears that sometimes treating all the patient's problems at the same time may cause more problems than it solves. Hopefully future research in this area will give us clarity and direction regarding this difficult issue."

AF is an irregular, often rapid heart rate that can cause poor blood flow. AF increases the risk of stroke from blood clots that form in the heart. When a clot breaks loose, it can then be carried to the brain and cause a stroke.

Some heart attacks are treated with angioplasties (an opening of the artery with a tiny inflatable balloon). Patients with AF or those who have undergone an angioplasty are often treated with anticoagulant drugs (blood thinners).

One common treatment method called dual therapy uses an anticoagulant and an antiplatelet drug together. Antiplatelet drugs help prevent the blood from clotting.

Triple therapy adds an additional anticoagulant to the mix.

One of the major complications of anticoagulants is an increased risk of bleeding. Triple therapy can increase this risk.

Dr. Hess and team studied almost 5,000 patients age 65 or older. All patients had a history of AF and had undergone an angioplasty.

Only 28 percent of these patients were discharged from the hospital on triple therapy, compared to 72 percent discharged on dual therapy.

These patients were often admitted to the hospital on the anticoagulant drug warfarin (brand name Coumadin), and were sent home with an additional anticoagulant and an antiplatelet drug.

These researchers looked for major cardiac events, such as death, readmission due to a heart attack or stroke and readmission due to bleeding.

Dr. Hess and team found that the patients on triple therapy were just as likely to have major heart problems after discharge as those on dual therapy.

The risk of bleeding within two years of discharge was also more than 6 percent higher for those on triple therapy.

In an editorial about this study, Javier A. Valle, MD, and John C. Messenger, MD, both from the Division of Cardiology at the University of Colorado School of Medicine, wrote "[for preventing major adverse cardiac events] more does not appear to be better."

Drs. Valle and Messenger concluded by asking, "Can we replace 'more' with a better alternative?"

The answer, they said, is "not yet."

This study was published in the August issue of the Journal of the American College of Cardiology.

No funding sources or conflicts of interest were disclosed.

Review Date: 
July 31, 2015
Last Updated:
August 9, 2015