About 10% of patients who receive dual antiplatelet therapy (DAT) after PCI have an indication for oral anticoagulation (OAC) and are thus treated with triple therapy. The standard ADP–receptor blocker in this setting is clopidogrel. Data regarding prasugrel as part of triple therapy is not available.

We analyzed a consecutive series of 377 patients who underwent DES implantation and have an indication for oral anticoagulation between 2/2009 and 12/2011 and were treated with a six month regimen of aspirin and OAC with either prasugrel or clopidogrel. The primary endpoint was a composite of TIMI major and minor bleeding at 6 months. The secondary endpoint was a composite of death, MI, ischemic stroke and definite stent thrombosis.

21 patients (5.6%) received prasugrel instead of clopidogrel. TIMI major and minor bleeding occurred significantly more often in the prasugrel as compared to the clopidogrel group (6 (33.1%) vs. 24 (7.0%); OR 4.6, 95% CI [2.1–10.5], p<0.001). There was no significant difference regarding the combined ischemic secondary endpoint (2 (10.3%) vs. 25 (7.1%); OR 1.4, 95% CI [0.6–6.1], p=0.61).

Prasugrel as part of triple therapy is associated with an increased rate of bleeding as compared to clopidogrel. The results of this study call for caution in the use of prasugrel as part of triple therapy until further data is available.