%0 Journal Article
%T Bleeding Complication of Triple Therapy of Rivaroxaban, Prasugrel, and Aspirin: A Case Report and General Discussion
%A Dane D. Gruenebaum
%A Ahmad Alsarah
%A Osama Alsara
%A Heather Laird-Fick
%J Case Reports in Cardiology
%D 2014
%I Hindawi Publishing Corporation
%R 10.1155/2014/293476
%X Hemorrhagic side effects are the bane of oral anticoagulation. Despite careful selection of medications and close monitoring, some adverse events are unavoidable. The available literature about the risks of triple oral anticoagulation therapy versus dual antiplatelet therapy does not address all of the medication combinations currently available. This report describes a patient with atrial fibrillation and recent stent placement who developed severe, recurrent epistaxis on aspirin, prosugrel, and rivaroxaban. We believe this is the first case report of severe bleeding with this combination, and it may help provide insights into the risk for other patients. 1. Introduction Several options, with well-described bleeding risks, exist for the chemoprophylaxis of thrombotic complications of either atrial fibrillation or coronary stents in isolation. However, therapy is less clear when the two conditions are comorbid. The ˇ°gold standardˇ± therapies differ for each and provide suboptimal risk reduction for the other condition. For example, the combination of aspirin and a thienopyridine inhibitor is recommended to prevent in-stent thrombosis but is inferior to warfarin or the newer oral anticoagulants for the prevention of stroke in atrial fibrillation. As a result, some clinicians have utilized both gold standard therapies simultaneously, resulting in triple oral antithrombotic therapy. While this strategy theoretically minimizes the risk of thrombotic complications, it may increase the risk of bleeding beyond the benefits gained. The net risk-benefit ratio for patients for patients on triple antithrombotic therapy should drive treatment decisions, yet it is often unclear. 2. Case A 55-year-old Caucasian male presented to the emergency department for one-day history of intractable nausea and vomiting and was found to be in atrial fibrillation with rapid ventricular response. He had a known history of paroxysmal atrial fibrillation but had previously refused warfarin therapy. His past medical history was otherwise significant for congestive heart failure preserved ejection fraction, coronary artery disease treated with a bare metal stent six months prior, diabetes mellitus type 2, hypertension, gout, and chronic kidney disease stage 3 (creatinine clearance 30). His home medications included prasugrel, aspirin atorvastatin, clonidine, furosemide, potassium chloride, amlodipine, insulin, allopurinol, and hydralazine. His nausea and vomiting were treated with supportive care and he was started on heparin and diltiazem drip for his atrial fibrillation. Cardiology
%U http://www.hindawi.com/journals/cric/2014/293476/