Fatal bleedings with prasugrel as part of triple antithrombotic therapy.

Fatal Bleedings With Prasugrel as Part of Triple Antithrombotic Therapy Hemorragias mortales relacionadas con un tratamiento antitrombótico triple que incluye prasugrel To the Editor, Triple antithrombotic therapy with aspirin, clopidogrel, and warfarin is used in about 5% of patients after coronary stent implantation, mostly due to atrial fibrillation and left ventricular thrombosis. 1 This antithrombotic combination has a higher risk of bleeding than dual antiplatelet therapy or warfarin. The third-generation P2Y 12 inhibitor, prasugrel, has been shown to be more effective that clopidogrel in patients with acute coronary syndromes undergoing angioplasty; however, this drug increased bleeding. 2 A higher risk of bleeding has recently been reported when prasugrel, rather than clopidogrel, was used in patients with coronary stents and an indication for warfarin, 3 although with no fatal cases. We report 2 cases of fatal bleeding in patients undergoing primary angioplasty due to an ST-elevation myocardial infarction, with subsequent initiation of warfarin. The first case was a 58-year-old male smoker weighing 85 kg who was hypertensive and dyslipidemic and who presented with an anterior ST-elevation myocardial infarction and severe left ventricular dysfunction. Creatinine, hemoglobin, and platelet count on admission were normal. Dual antiplatelet therapy using aspirin and prasugrel was started on admission. Bivalirudin was used during angioplasty, with bailout abciximab and balloon counterpulsation due to no-reflow and no ST-resolution after stent implantation in the left anterior descending artery. On postadmis-sion day 9, revascularization was completed by stenting of a severely narrowed left circumflex artery. During rehabilitation, a left ventricular thrombus was detected on echocardiography and warfarin was added to dual antiplatelet therapy. Four months later, the patient was admitted due to progressive loss of consciousness: a left temporoparietal intraparenchymal hemorrhage was detected on computed tomography scan. The international normalized ratio (INR) was 3.49 (previous values were a maximum of 2.5-3.0). Hemoglobin and platelet count were normal. The patient died despite immediate neurosurgery. Autopsy revealed bleeding from a small arteriovenous malformation. The second case was a 68-year-old man weighing 96 kg, who was hypertensive and diabetic and who had no history of heart disease or bleeding. He was admitted with an anterior ST-elevation myocardial infarction and severe left ventricular dysfunction. His INR on admission was 1.15. His proximal left anterior descending artery was treated with stenting. Dual antiplatelet therapy was started with aspirin and prasugrel. In the following days, the patient's hemodynamics improved slowly, cardiac rhythm was atrial fibrillation with frequent …