Clinical Question: Is oral anticoagulant monotherapy safer and more effective than dual antithrombotic therapy in patients with atrial fibrillation (AF), coronary artery disease (CAD), and advanced chronic kidney disease (CKD)?
Background: Current guidelines recommend dual antithrombotic therapy for the first 12 months after coronary intervention and acute myocardial infarction in patients with AF, followed by oral anticoagulant (OAC) monotherapy thereafter in stable CAD. Data are limited regarding optimal management for patients presenting with AF, CAD, and advanced CKD.
Study Design: Retrospective cohort study
Setting: TriNetX Research Network, a global federated database of 144 healthcare organizations across 18 countries
Synopsis: This study compared OAC monotherapy (apixaban, rivaroxaban, edoxaban, dabigatran, or warfarin) against dual antithrombotic therapy (OAC plus aspirin, clopidogrel, ticagrelor, prasugrel, or cilostazol) in 12,589 propensity-matched pairs of adults with AF, CAD, and advanced (stage 4, 5, or dialysis-dependent) CKD. Over 12 months, patients in the monotherapy group demonstrated a significantly lower risk of major adverse cardiovascular events (HR, 0.84), acute ischemic stroke, and acute myocardial infarction, while improving safety outcomes by reducing major bleeding, minor bleeding, and intracranial hemorrhage risks. All-cause mortality showed no significant difference between the two treatment arms. Notably, dual therapy was the dominant strategy before matching, used in roughly three of every four patients, highlighting how common dual antithrombotic therapy remains in routine clinical practice. Because this is an observational database study, it is limited by potential incomplete capture or misclassification of clinical events occurring outside participating facilities. Subgroup analyses of individual agents were underpowered, and the data lacked precise medication doses or durations; therefore, clinicians should interpret class-wide benefits carefully before switching highly individualized regimens.
Bottom Line: In patients with AF, CAD, and advanced CKD, OAC monotherapy is at least as effective as dual antithrombotic therapy and is likely safer.
Citation: Kao CC, et al. Antithrombotic strategies in advanced chronic kidney disease: real-world comparison of oral anticoagulation alone vs dual antithrombotic therapy. Mayo Clin Proc. 2026;101(5):727-742. https://doi.org/10.1016/j.mayocp.2025.12.028.
Dr. Pumilia
Dr. Pumilia practices outpatient general internal medicine at Erlanger Hospital and is an assistant professor of medicine at University of Tennessee Health Science Center College of Medicine, both in Chattanooga, Tenn.