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Gustav Smith

Associate professor

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Triple antithrombotic therapy following an acute coronary syndrome: prevalence, outcomes and prognostic utility of the HAS-BLED score.


  • Gustav Smith
  • Mattias Wieloch
  • Sasha Koul
  • Oscar Braun
  • Jonathan Lumsden
  • Emil Rydell
  • Jenny Öhman
  • Fredrik Scherstén
  • Peter Svensson
  • Jesper vanderPals

Summary, in English

Aims: The aim of this study was to evaluate the prevalence of triple antithrombotic therapy (TT) (warfarin, aspirin and clopidogrel) in patients following an acute coronary syndrome (ACS), the bleeding risk compared to double antiplatelet therapy (DAPT) (aspirin and clopidogrel) and evaluate the accuracy of the HAS-BLED risk score in predicting serious bleeding events in TT patients. Methods and results: We retrospectively identified all ACS patients on TT upon discharge from the Coronary Care Unit at Skane University Hospital between 2005 and 2010. TT patients were compared to age- and sex-matched control patients discharged with DAPT. Major bleeding was defined in accordance with the HAS-BLED derivation study. A total of 2,423 patients were screened, of whom 159 (6.6%) were on TT. The mean age was 67.2 (±0.9) years. The most common indication for TT was atrial fibrillation (n=63, 39.6%) followed by apical akinesia (n=60, 37.8%), and the mean duration of TT was 3.7 (±0.3) months. Upon termination of TT, warfarin was discontinued in 82 (52.2%) patients and clopidogrel in 57 (36.3%) patients. The cumulative incidence of spontaneous bleeding events was significantly higher with TT compared to DAPT at one year (10.2% vs. 3.2%; p=0.01). The HAS-BLED score significantly predicted spontaneous bleeding events in TT patients (area under the receiver operating characteristic [ROC] curve 0.67; 95% CI=0.54-0.79; p=0.048). Conclusions: TT was relatively common following acute coronary syndrome and was associated with a threefold increase in major bleeding compared to DAPT at one year. The HAS-BLED risk score predicted bleeding events with moderate accuracy.


  • EXODIAB: Excellence of Diabetes Research in Sweden
  • EpiHealth: Epidemiology for Health
  • Cardiology
  • Department of Clinical Sciences, Malmö
  • Clinical Coagulation, Malmö
  • Arrhytmias and Cardiac Device treatment
  • Molecular Cardiology

Publishing year












Document type

Journal article


Société Europa Edition


  • Cardiac and Cardiovascular Systems



Research group

  • Clinical Coagulation, Malmö
  • Arrhytmias and Cardiac Device treatment
  • Molecular Cardiology


  • ISSN: 1969-6213