Optimal antithrombotic strategy for patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention: updated meta-analysis of randomised controlled trials
Abstract Background The optimal antithrombotic strategy for the growing proportion of patients with indications for both dual antiplatelet therapy and long-term anticoagulation remains controversial, with recent randomized trials published and mixed recommendations in guidelines. We meta-analysed bleeding and cardiovascular outcomes comparing dual versus triple and non-vitamin K oral anticoagulants (NOAC) versus vitamin K oral anticoagulants (VKA) antithrombotic regimens. Methods MEDLINE, Embase and Cochrane databases were searched for original randomised trials with relevant search terms from January 1980-December 2019. Two authors evaluated studies for inclusion and extracted data to pool efficacy and safety endpoints. Results The search yielded 331 articles, with 22 full-texts reviewed and six randomised trials totalling 12,146 patients included. Dual antithrombotic strategies had reduced TIMI major and minor bleeding (odds ratios 0.59, 95% confidence interval 0.44–0.80), as well as all, major, and minor bleeding (odds ratios 0.55–0.59, all P<0.05), with no differences in mortality, myocardial infarction, stroke, stent thrombosis or composite cardiovascular events (odds ratio 0.91–1.26, all P>0.05), compared with triple antithrombotic strategies in six trials. NOAC regimens had lower TIMI major and minor bleeding (odds ratio 0.64, 0.49–0.85), as well as major, minor and intracranial bleeding (odds ratios 0.36–0.66, all P<0.05), and similar no differences in mortality or all cardiovascular endpoints (odds ratios 0.85–1.13, all P>0.05), compared with VKA regimens in four trials. Conclusion Dual antithrombotic therapy with NOAC had significantly reduced bleeding without increase in cardiovascular events and mortality compared to their counterparts, and should generally be recommended in patients needing dual antiplatelet and long term anticoagulation therapy. Funding Acknowledgement Type of funding source: None