What is the recommendation for the use of vitamin K antagonists for secondary prevention after STEMI in the era of DAPT?
Previous recommendations for the use of vitamin K antagonists, either alone or in combination with low-dose aspirin, for secondary prevention or for reducing the risk of systemic thromboembolism after STEMI, must be reconsidered in the era of DAPT. Due to the availability of several P2Y12 receptor inhibitors, the reliance on vitamin K antagonists as an alternative to aspirin for aspirin-allergic patients has virtually been eliminated. A meta-analysis of RCTs comparing warfarin plus aspirin to aspirin alone in patients with ACS showed that in studies with an international normalized ratio goal of 2.0 to 3.0, combination therapy was associated with a significant reduction in major adverse events at the expense of an increased risk of major bleeding. However, none of the trials included patients treated with primary PCI or DAPT.