We applaud Hansen and colleagues1 for calling attention to the risk of bleeding with single or combined therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Although the authors highlight the increased risk of bleeding with all combinations of these medications, we believe that one observation in this article is worthy of special emphasis, since it is not only important but also may be unknown to many clinicians. Figure 3 of their article1(p1438) shows that the risk of bleeding for patients receiving combined treatment with aspirin and clopidogrel, often referred to as dual antiplatelet therapy (DAPT), was significantly higher than the risk for patients treated with warfarin alone. This finding should be important to clinicians who make treatment recommendations to patients with atrial fibrillation and vascular disease. It is consistent with the earlier Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events (ACTIVE W) trial,2 in which the risk of minor bleeding and total bleeding was significantly higher for those treated with DAPT than with oral anticoagulation.
Ziegelstein RC, Green A, Sauder M. Dual Antiplatelet Therapy and the Risk of Bleeding. Arch Intern Med. 2011;171(8):782-790. doi:10.1001/archinternmed.2011.147