Bleeding Complications Associated With Combinations of Aspirin, Thienopyridine Derivatives, and Warfarin in Elderly Patients Following Acute Myocardial Infarction

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Abstract
A large body of literature supports the use of aspirin for secondary prevention in patients with acute myocardial infarction (AMI).1 However, some patients with AMI also require long-term or short-term anticoagulation with warfarin sodium for indications such as atrial fibrillation, thromboembolic disease, and mechanical heart valves or for the prevention of left ventricular mural thrombus formation after anterior AMI.2 Furthermore, patients with AMI who undergo percutanous coronary intervention (PCI) with stenting benefit from thienopyridine derivatives (ticlopidine hydrochloride or clopidogrel bisulfate) in addition to aspirin.3 The combination of aspirin and a thienopyridine derivative should be prescribed for 2 to 4 weeks after PCI to prevent acute in-stent thrombosis and up to 6 to 12 months after brachytherapy or drug-eluding stents.4-7 In addition, recent trials have suggested that the long-term addition of clopidogrel or warfarin to an aspirin treatment regimen in patients with acute coronary syndrome leads to further reduction in fatal and nonfatal cardiovascular events and is, therefore, considered to be superior to aspirin alone.8-11 Finally, the combination of aspirin, warfarin, and thienopyridine derivatives is used in patients with permanent atrial fibrillation who receive drug-eluting stents following AMI.3,4