Rethinking the Antithrombotic Regimen: The Case Against Underdosing in High-Risk Patients
A new editorial in *Heart* critically examines the long-term antithrombotic strategy for patients with atrial fibrillation (AF) and stable coronary artery disease (CAD), challenging the current trend towards minimal therapy. The piece highlights the delicate balance between preventing ischemic events and mitigating bleeding risk, a core principle of clinical pharmacology and pharmacokinetics. It discusses the paradigm shift from triple therapy (warfarin plus dual antiplatelets) to dual antithrombotic therapy (DAT) using direct oral anticoagulants (DOACs), and scrutinizes the guideline-recommended move to oral anticoagulation (OAC) alone. The analysis references key randomized controlled trials, including the AFIRE study, to question whether an overemphasis on reducing adverse drug reactions like bleeding may inadvertently increase the risk of thrombotic events through therapeutic underdosing.
Study Significance: This debate is central to pharmacodynamics and personalized medicine in cardiology, directly impacting drug efficacy and safety profiles. For pharmacologists and clinicians, it underscores the need for refined therapeutic drug monitoring and a deeper understanding of drug–drug interactions in complex, multimorbid patients. The discussion informs the ongoing optimization of dose-response curves and therapeutic windows for anticoagulants, a critical area in modern cardiovascular pharmacotherapy.
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