AQUATIC Trial – Aspirin + Anticoagulation
AQUATIC Trial – Aspirin + Anticoagulation
Source: Medscape, ESC 2025, Sept 11, 2025
1. Background
• Many patients with chronic CAD + AF receive both aspirin and anticoagulation.
• AQUATIC tested if dual therapy (aspirin + OAC) is better than OAC alone.
2. Design
• ~900 patients, mean age 72, mostly male, high ischemic risk (prior MI, CHA₂DS₂-VASc ~4).
• Anticoagulation: 89% DOAC, rest warfarin.
• Randomized to OAC + aspirin vs OAC + placebo.
3. Results (2 years, stopped early for harm)
• Primary events: 16.9% dual vs 12.1% OAC alone (HR 1.53).
• All-cause death: 13.4% vs 8.4% (HR 1.72).
• Major bleeding: 10.2% vs 3.4% (HR 3.3).
• Conclusion: Combination clearly worse.
4. Triple Therapy (ACC/AHA & ESC Guidelines)
• Triple therapy (OAC + aspirin + clopidogrel) is used only briefly after PCI with stent in patients who also need anticoagulation.
• Recommended duration: ≤1 week, up to 1 month in very high ischemic risk cases (complex PCI, recent ACS, diffuse multivessel coronary disease with diabetes or chronic kidney disease, or prior stent thrombosis).
• Then → step down to dual therapy (OAC + clopidogrel) for the rest of the 6–12 month post-PCI window.
• Beyond 12 months → OAC alone is best.
5. Lessons
• Large absolute harm: NNH = 21 for ischemic events, 15 for bleeding.
• Results align with AFIRE and EPIC-CAD.
• The coagulation system is delicate — combining aspirin + OAC causes additive harm, not additive benefit.
6. Take-home
• Outside the 6–12 months post-stent window, in patients with chronic CAD and AF:
• OAC alone is best.
• Dual or triple therapy is the wrong answer for long-term management.
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