Dual Versus Triple Antithrombotic Therapy After Acute Coronary Syndrome or Percutaneous Coronary Intervention in Patients With Atrial Fibrillation: An Updated Meta-Analysis

Abstract Aims Safety and efficacy of antithrombotic regimens in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) may differ based on clinical presentation. We sought to compare double vs. triple antithrombotic therapy (DAT vs. TAT) in AF patients with or without acute coronary syndrome (ACS) undergoing PCI. Methods and results A systematic review and meta-analysis was performed using PubMed to search for non-vitamin K antagonist oral anticoagulant (NOAC)-based randomized clinical trials. Data on subgroups of ACS or elective PCI were obtained by published reports or trial investigators. A total of 10 193 patients from four NOAC trials were analysed, of whom 5675 presenting with ACS (DAT = 3063 vs. TAT = 2612) and 4518 with stable coronary artery disease (SCAD; DAT = 2421 vs. TAT = 2097). The primary safety endpoint of ISTH major bleeding or clinically relevant non-major bleeding was reduced with DAT compared with TAT in both ACS (12.2% vs. 19.4%; RR 0.63, 95% CI 0.56–0.71; P < 0.0001; I2 = 0%) and SCAD (14.6% vs. 22.0%; RR 0.68, 95% CI 0.55–0.85; P = 0.0008; I2 = 66%), without interaction (P-int = 0.54). Findings were consistent for secondary bleeding endpoints, including intra-cranial haemorrhage. In both subgroups, there was no difference between DAT and TAT for all-cause death, major adverse cardiovascular events, or stroke. Myocardial infarction and stent thrombosis were numerically higher with DAT vs. TAT consistently in ACS and SCAD (P-int = 0.60 and 0.86, respectively). Findings were confirmed by multiple sensitivity analyses, including a separate analysis on dabigatran regimens and a restriction to PCI population. Conclusions DAT, compared with TAT, is associated with lower bleeding risks, including intra-cranial haemorrhage, and a small non-significant excess of cardiac ischaemic events in both patients with or without ACS.

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Antithrombotic therapy after acute coronary syndrome and/or percutaneous coronary intervention in atrial fibrillation: finding the sweet spot

European Heart Journal ◽

10.1093/eurheartj/ehz823 ◽

2019 ◽

Vol 40 (46) ◽

pp. 3768-3770 ◽

Cited By ~ 3

Author(s):

Renato D Lopes ◽

Hwanhee Hong ◽

John H Alexander

Keyword(s):

Atrial Fibrillation ◽

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Antithrombotic Therapy ◽

Coronary Intervention ◽

Sweet Spot ◽

Coronary Syndrome ◽

Percutaneous Coronary

Abstract

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Intracranial haemorrhages vs. stent thromboses with direct oral anticoagulant plus single antiplatelet agent or triple antithrombotic therapy: a meta-analysis of randomized trials in atrial fibrillation and percutaneous coronary intervention/acute coronary syndrome patients

EP Europace ◽

10.1093/europace/euz345 ◽

2020 ◽

Vol 22 (4) ◽

pp. 538-546 ◽

Cited By ~ 7

Author(s):

Mattia Galli ◽

Felicita Andreotti ◽

Italo Porto ◽

Filippo Crea

Keyword(s):

Atrial Fibrillation ◽

Percutaneous Coronary Intervention ◽

Antithrombotic Therapy ◽

Randomized Trials ◽

Coronary Intervention ◽

Direct Oral Anticoagulant ◽

Coronary Syndrome ◽

Thrombosis Risk ◽

Percutaneous Coronary ◽

Triple Antithrombotic Therapy

Abstract Aims To assess the efficacy-safety profile of dual antithrombotic therapy (DAT) including direct oral anticoagulant (DOAC) vs. triple antithrombotic therapy (TAT) in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Methods and results Randomized trials of AF patients with ACS/PCI, comparing DAT using DOACs against TAT, were selected. Overall, 11 161 studies were screened, 458 trials assessed, and four included, comprising 10 234 patients followed for a mean of 11 months. DAT compared to TAT resulted in significant reductions of trial-defined primary safety outcome [odds ratio (OR) 0.63, 95% confidence interval (CI) 0.50–0.79, number needed to treat (NNT) 17] and of thrombolysis in myocardial infarction (TIMI) major bleeding (OR 0.54, 95% CI 0.41–0.70, NNT 76) and in a numerical reduction of intracranial haemorrhage (OR 0.50, 95% CI 0.21–1.19, NNT 314), which became significant after exclusion of DOACs from TAT and vitamin K antagonist from DAT arms (OR 0.31, 95% CI 0.15–0.64). There were no significant differences in the risks of cardiovascular or any deaths or stroke, but with DAT, there was a numerical increase in myocardial infarctions (MIs) (OR 1.23, 95% CI 0.99–1.54, estimated NNT for an additional harmful outcome (NNTH) 151), which became significant in the ACS/PCI subgroup (OR 1.43, 95% CI 1.02–2.00), and a 60% significant increase in stent thrombosis risk (OR 1.60, 95% CI 1.02–2.52; NNTH 274). Conclusion Dual antithrombotic therapy, compared to TAT, conferred a significantly reduced risk of overall bleeding but with a significant increase of stent thrombosis risk in the overall population and a significant 43% increase of MI in the ACS/PCI subgroup.

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