Abstract 14950: Meta-analysis of Oral Anticoagulants With Dual vs Single Antiplatelet Therapy in Patients After Coronary Intervention

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Alexandros Briasoulis ◽  
Shikha Sharma ◽  
Sagar Mallikethi-Reddy ◽  
Nikolaos Papageorgiou ◽  
Mohan Palla ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Cohort Studies ◽  
Antiplatelet Therapy ◽  
Major Bleeding ◽  
Antithrombotic Therapy ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Coronary Syndrome ◽  
All Cause Mortality ◽  
Triple Antithrombotic Therapy

Background: Combined use of dual antiplatelet therapy with oral anticoagulation (OAC) is required in some patients with after coronary artery stenting or acute coronary syndrome (ACS). Methods: We performed a meta-analysis of the comparative effects of triple antithrombotic therapy (TT) vs OAC with single antiplatelet therapy (DT) on all-cause mortality, stroke, cardiovascular death, myocardial infarction, target vessel revascularization and major bleeding. We conducted an EMBASE and MEDLINE search for prospective controlled trials and cohort studies of patients requiring anticoagulation after coronary stenting. Results: We identified 3 prospective controlled studies and 5 cohort studies, which compared TT vs dual therapy (DT). We identified 4 prospective controlled and 6 cohort studies with 4564 patients on TT and 1848 on DT with an average follow up duration of 10.1 months. TT is associated with similar rates of all-cause mortality, stroke and major bleeding but significantly lower rates of myocardial infarction compared to DT (mainly OAC plus clopidogrel). Conclusion: Triple antithrombotic therapy is associated with similar mortality and bleeding rates but less myocardial infarctions compared with OAC and single antiplatelet therapy.

scholarly journals Efficacy and Safety of Oral Anticoagulants in Patients with Systolic Heart Failure in Sinus Rhythm: A Systematic Review and Meta-analysis of Randomized Controlled Trials and Cohort Studies

TH Open ◽  
2020 ◽  
Vol 04 (04) ◽  
pp. e383-e392
Author(s):  
Marie H. Nygaard ◽  
Anne-Mette Hvas ◽  
Erik L. Grove
Keyword(s):  
Heart Failure ◽  
Sinus Rhythm ◽  
Cohort Studies ◽  
Antiplatelet Therapy ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Controlled Trials ◽  
Efficacy And Safety ◽  
Randomized Controlled ◽  
All Cause Mortality

Abstract Introduction There is conflicting evidence on the risk–benefit ratio of oral anticoagulants (OAC) in heart failure (HF) patients without atrial fibrillation. We aimed to evaluate the efficacy and safety of OAC in HF patients in sinus rhythm. Methods A systematic literature search was conducted using PubMed and Embase. We included randomized controlled trials (RCT) and cohort studies, comparing OAC with antiplatelet or no treatment/placebo in patients with HF. Outcomes evaluated were stroke, myocardial infarction (MI), all-cause mortality, and major bleeding. Results Five RCTs and three cohort studies were included. OAC was associated with a reduced risk of ischemic stroke when compared with no treatment/placebo (odds ratio [OR] = 0.67, 95% confidence interval [CI]: [0.47, 0.94]) and antiplatelet therapy (OR = 0.55, 95% CI: [0.37, 0.81]). No significant reduction was found in MI, when OAC was compared with no treatment/placebo (OR = 0.82, 95% CI: [0.63, 1.07]) or antiplatelet therapy (OR = 1.04, 95% CI: [0.60, 1.81]). The all-cause mortality analysis showed no significant reduction when comparing OAC with no treatment/placebo (OR = 0.99, 95% CI: [0.87, 1.12]) or antiplatelet therapy (OR = 1.00, 95% CI: [0.86, 1.16]). The nonsignificant effect of OAC on all-cause mortality was supported by a meta-analysis of the three cohort studies (OR = 1.02, 95% CI: [0.75, 1.38]). Patients treated with OAC had a significantly higher risk of major bleeding than patients receiving antiplatelet therapy (OR = 2.16, 95% CI: [1.55, 3.00]) and a numerically higher risk when compared with no treatment/placebo (OR = 2.38, 95% CI: [0.87, 6.49]). Conclusion The present study does not support the routine use of OAC in patients with HF in sinus rhythm.

scholarly journals Bleeding and ischaemic outcomes in patients treated with dual or triple antithrombotic therapy: systematic review and meta-analysis

2019 ◽  
Vol 5 (4) ◽  
pp. 226-236 ◽  
Author(s):  
Paul M Haller ◽  
Patrick Sulzgruber ◽  
Christoph Kaufmann ◽  
Bastiaan Geelhoed ◽  
Juan Tamargo ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Stent Thrombosis ◽  
Antithrombotic Therapy ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Power Calculation ◽  
Coronary Syndrome ◽  
High Bleeding Risk ◽  
Triple Antithrombotic Therapy

Abstract Aims The combination of oral anticoagulation with a P2Y12 inhibitor and aspirin in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is associated with a high bleeding risk. Dual antithrombotic therapy (DAT) with omission of aspirin is a promising option to reduce bleedings, but carries a yet unknown risk of ischaemic events. We therefore sought to systematically review and analyse randomized controlled trials investigating DAT vs. triple antithrombotic therapy (TAT) in patients with AF following PCI and/or acute coronary syndrome (ACS). Methods and results We included four trials with overall 9317 patients (5039 DAT, 4278 TAT) in our analysis. Dual antithrombotic therapy was associated with a significant reduction in thrombolysis in myocardial infarction major bleeding [hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.42–0.65; P = 0.0001], while the composite trial-defined ischaemic endpoint did not differ significantly between DAT and TAT (HR 0.98, 95% CI 0.79–1.22; P = 0.88). There was also no difference regarding the occurrence of myocardial infarction (MI; HR 1.16, 95% CI 0.92–1.46; P = 0.21) or stent thrombosis (HR 1.25, 95% CI 0.69–2.26; P = 0.46). Absolute numbers for MI were 131/4278 (3.1%) with TAT and 182/5039 (3.6%) with DAT, and for stent thrombosis 32/4278 (0.75%) and 52/5039 (1%), respectively. A post hoc power calculation based on the size and event rate of this meta-analysis revealed 80% power to detect a 37% and 100% increase in MI and stent thrombosis, respectively. Conclusion Dual antithrombotic therapy significantly reduces bleedings compared with TAT and seems to have a similar effect in preventing ischaemic endpoints in AF patients post-PCI or ACS. Future investigations are needed to determine its applicability specifically in patients at high risk of ischaemic outcomes.

Aspirin-omitted dual antithrombotic therapy in non-valvular atrial fibrillation patients presenting with acute coronary syndrome or undergoing percutaneous coronary intervention: results of a meta-analysis

2020 ◽  
Author(s):  
Cheng-Feng Luo ◽  
Pei Mo ◽  
Guo-Qiang Li ◽  
Shi-Ming Liu
Keyword(s):  
Myocardial Infarction ◽  
Atrial Fibrillation ◽  
Percutaneous Coronary Intervention ◽  
Stent Thrombosis ◽  
Major Bleeding ◽  
Antithrombotic Therapy ◽  
Meta Analysis ◽  
Coronary Intervention ◽  
Coronary Syndrome ◽  
Percutaneous Coronary

Abstract Aims To investigate the effects of aspirin-omitted dual antithrombotic therapy (DAT) on myocardial infarction and stent thrombosis in non-valvular atrial fibrillation (NVAF) patients presenting with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Methods and results A systematic review and meta-analysis were performed using PubMed to search for randomized clinical trials comparing DAT with triple antithrombotic therapy (TAT) in this setting. Three trials involving 8845 patients were included (4802 and 4043 patients treated with DAT and TAT, respectively). There were no significant differences in all-cause death and stroke between the aspirin-omitted DAT group and TAT group. Otherwise, the incidence of myocardial infarction was significantly higher with aspirin-omitted DAT vs. TAT [odds ratio (OR): 1.29, 95% confidence interval (CI): 1.02–1.63; P = 0.04; I2 = 0%]. Similarly, the incidence of stent thrombosis increased in patients treated with aspirin-omitted DAT vs. TAT (OR: 1.61, 95% CI: 1.02–2.53; P = 0.04; I2 = 0%). The occurrence of major bleeding and clinically relevant non-major bleeding events, as defined by the International Society on Thrombosis and Haemostasis, was significantly lower with aspirin-omitted DAT vs. TAT (OR: 0.61, 95% CI: 0.48–0.78; P = 0.02; I2 = 76%). Similar results were found according to the International Society on Thrombosis and Haemostasis major bleeding, Thrombolysis in Myocardial Infarction major or minor bleeding, and Thrombolysis in Myocardial Infarction major bleeding scales. Conclusion Aspirin-omitted DAT reduces the occurrence of bleeding episodes, with a higher rate of myocardial infarction and stent thrombosis in NVAF patients presenting with ACS or undergoing PCI.

scholarly journals Radial versus femoral access for coronary angiography and interventions: a systematic review and meta-analysis of randomized trials

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Chiarito ◽  
D Cao ◽  
J Nicolas ◽  
A Roumeliotis ◽  
D Power ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Angiography ◽  
Major Bleeding ◽  
Randomized Trials ◽  
Significant Risk ◽  
Number Needed To Treat ◽  
Femoral Access ◽  
Coronary Syndrome ◽  
Radial Access ◽  
All Cause Mortality

Abstract Background The presence of any benefits associated with radial or femoral access among patients undergoing coronary angiography and percutaneous coronary interventions (PCI) is still debated. Purpose Our aim is to provide a comprehensive quantitative appraisal of the effects of access site on the risks of stroke, myocardial infarction, and major bleeding in patients undergoing coronary angiography with or without PCI. Methods In January 2020, we searched PubMed, Embase, and meeting abstracts for randomized trials comparing radial versus femoral access for coronary angiography with or without subsequent PCI. Odds ratios (OR) were used as metric of choice for treatment effects with random-effects models. Co-primary efficacy endpoints were stroke and myocardial infarction. Primary safety endpoint was major bleeding. Secondary endpoints were all cause mortality and vascular complications. Heterogeneity was assessed with the I-squared index. This study is registered with PROSPERO. Results We identified 31 trials, including 30,414 patients. Risks of stroke (OR 1.11, 95% CI 0.76–1.64, I2=0%) and myocardial infarction (OR 0.90, 95% CI 0.79–1.03, I2=0%) were comparable between radial and femoral access. Radial access was associated with a reduction for the risk of major bleeding as compared to femoral access (OR 0.53, 95% CI 0.42–0.67, I2=3.3%) with a number needed to treat of 92. Findings were consistent regardless clinical features and procedure performed, with the only exception of an increased benefit of the radial access in patients with chronic coronary syndrome (p forinteraction=0.005). The risk for all-cause mortality (OR 0.73, 95% CI 0.61–0.89, I2=0%) and vascular complication (OR 0.32, 95% CI 0.23–0.44, I2=16.7%) was significantly lower in the radial compared to femoral access group. Conclusions In patients undergoing coronary angiography with or without PCI, radial compared to femoral access did not reduce the risk of stroke and myocardial infarction, with no impact on the effect estimates of clinical presentation, age, gender, or subsequent PCI. Whereas, radial access is associated with a significant risk reduction of major bleeding as compared to femoral access. The benefit favoring radial access is of important clinical relevance in view of the relatively low number needed to treat to prevent a major bleeding and the significant impact on mortality. Funding Acknowledgement Type of funding source: None

Abstract 12901: Novel Oral Anticoagulants Are Associated With Decreased Recurrence of Venous Thromboembolism in Patients With Cancer: An Updated Meta-Analysis

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sunil Upadhaya ◽  
Seetharamprasad Madala ◽  
Sunil Badami
Keyword(s):  
Venous Thromboembolism ◽  
Major Bleeding ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Novel Oral Anticoagulants ◽  
P Value ◽  
Patients With Cancer ◽  
Randomized Controlled ◽  
All Cause Mortality ◽  
Recurrent Vte

Introduction: Patients with cancer are at high risk for recurrent thromboembolic phenomenon. Use of novel oral anticoagulants (NOAC) for treatment of venous thromboembolism (VTE) in such patients is controversial. We conducted this updated meta-analysis to evaluate the pooled efficacy and safety of NOAC in patients with cancer. Methods: We did systematic search of PubMed and Cochrane library databases for randomized controlled trials comparing NOAC with low molecular weight heparin (LMWH) for VTE treatment in cancer patients till April 2020. The efficacy outcomes were recurrent VTE and all-cause mortality rates, and the primary safety outcome was incidence of major bleeding rate. Results: Four randomized controlled studies comparing NOAC with LMWH (1446 patients in NOAC group and 1448 patients in LMWH group) were included in our study. Use of NOAC lead to significant reduction in recurrent VTE rate (odds ratio (OR): 0.55 [0.36-0.84], I 2 = 45 %, p value = 0.006) (Figure 1). However, we did not find any significant difference in rate of major bleeding (OR: 1.30 [0.76-2.23], I 2 = 35%, p value = 0.34) (Figure 2) and all-cause mortality (OR: 1 [0.80 - 1.26], I 2 = 33%, p value = 0.98). Conclusions: This updated meta-analysis showed comparatively lower pooled recurrent VTE rate in patient being treated with NOAC, whereas similar rates of major bleeding and all-cause death. NOAC are more efficacious and has similar safety profile compared with LMWH.

Abstract 16401: Duration of Dual Antiplatelet Therapy in Coronary Heart Disease: A 60,000-patient Meta-analysis of Randomised Controlled Trials

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Anda Bularga ◽  
Mohammed Meah ◽  
Dimitrios Doudesis ◽  
Anoop S Shah ◽  
Nicholas L Mills ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Major Bleeding ◽  
Randomised Controlled Trials ◽  
Dual Antiplatelet Therapy ◽  
Meta Analysis ◽  
Controlled Trials ◽  
Short Term ◽  
All Cause Mortality ◽  
Standard Duration ◽  
Randomised Controlled

Introduction: Dual antiplatelet therapy (DAPT) is the cornerstone of pharmacological treatment for patients with acute coronary syndrome (ACS) and in those undergoing percutaneous coronary intervention for stable coronary disease. Despite widespread use, the optimal duration of DAPT remains uncertain. We present an updated meta-analysis comparing outcomes in short-term DAPT (≤ 6 months) versus long-term DAPT (≥ 12 months). Methods: Four major databases were searched for randomised controlled trials of interest. The primary outcome was all-cause mortality. Secondary safety outcomes included any bleeding and major bleeding. Efficacy outcomes included cardiovascular death, myocardial infarction, stent thrombosis, coronary revascularization and thrombotic stroke. Further subgroup analysis stratified by index presentation and a sensitivity analysis to evaluate shorter duration DAPT (≤3 months) was performed. Results: Nineteen randomised controlled trials were included (n=60,879) of which 8 compared shorter duration DAPT (≤3 months) with standard duration (12 months) (n=38,036). Short-term DAPT was associated with an apparent modest increase in myocardial infarction (risk ratio [RR] 1.09; 95% confidence interval [CI], 0.98-1.22) with a major reduction in bleeding (RR 0.68; 95% CI, 0.55-0.83) for major bleeding and (RR 0.66; 95% CI, 0.56-0.77 for any bleeding) and an overall apparent reduction in all-cause mortality (RR 0.90; 95% CI 0.81-1.01). These associations persisted when comparing shorter duration DAPT to standard duration. Subgroup analysis of patients with stable disease or ACS identified no significant heterogenicity in efficacy, safety or mortality outcomes. Conclusion: In the largest meta-analysis to date comparing duration of DAPT, we show that short (≤ 6 months) and shorter (≤ 3 months) DAPT is associated with continuing trends for small reductions in all-cause mortality irrespective of index presentation.

scholarly journals Direct Anticoagulants and Risk of Myocardial Infarction, a Multiple Treatment Network Meta-Analysis

Angiology ◽  
2019 ◽  
Vol 71 (1) ◽  
pp. 27-37 ◽  
Author(s):  
Péter Kupó ◽  
Zsolt Szakács ◽  
Margit Solymár ◽  
Tamás Habon ◽  
László Czopf ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Relative Risk ◽  
Randomized Clinical Trials ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Credible Interval ◽  
Control Group ◽  
Cardiovascular Safety ◽  
Coronary Syndrome

We assessed the cardiovascular safety of long-term direct-acting oral anticoagulant (DOAC) treatment. A search of the medical literature was performed from inception until May 31, 2019. Inclusion criteria were (1) randomized trial that assessed the clinical efficacy and/or safety of 1 or more DOAC, (2) control group including oral anticoagulation and/or antiplatelet and/or placebo treatment, and (3) the incidence of acute coronary syndrome during follow-up was reported. Fixed-effect and random-effects models were applied. The analyzed outcomes were myocardial infarction (MI), major bleeding, and mortality. Twenty-eight randomized clinical trials (196 761 patients) were included. Rivaroxaban was associated with a 21% reduction in the relative risk of MI when compared to placebo (relative risk [RR]: 0.79 [95% credible interval, CrI: 0.65-0.94]) and a 31% reduction (RR: 0.70 [95% CrI: 0.53-0.89]) when compared to dabigatran. Apixaban resulted in 24% (RR: 0.76 [95% CrI: 0.58-0.99]) and vitamin K antagonists anticoagulation resulted in 19% (RR: 0.81 [95% CrI: 0.65-0.98]) risk reduction compared to dabigatran. The computed probability of being the first best choice of treatment was 61.8% for rivaroxaban. Cardiovascular safety shows considerable heterogeneity among oral anticoagulants. Treatment with rivaroxaban is associated with reduced rate of MI.

3054Efficacy and safety of non-vitamin K oral anticoagulants in patients with atrial fibrillation and cancer

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
I Cavallari ◽  
G Verolino ◽  
G Patti
Keyword(s):  
Atrial Fibrillation ◽  
Venous Thromboembolism ◽  
Intracranial Hemorrhage ◽  
Major Bleeding ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Efficacy And Safety ◽  
Systemic Embolism ◽  
Patients With Cancer ◽  
All Cause Mortality

Abstract Background Anticoagulation in patients with cancer and atrial fibrillation (AF) is particularly challenging given the higher risk of both thrombotic and bleeding complications in this setting. Data regarding the efficacy and safety of non-vitamin K oral anticoagulants (NOACs) in AF patients with malignancy remain unclear. Purpose In the present meta-analysis we further investigate the efficacy and safety of NOACs compared to warfarin in patients with AF and cancer assuming that available studies may be individually underpowered for endpoints at low incidence, i.e. stroke, major and intracranial bleeding. Methods We performed a systematic review and meta-analysis of studies comparing the use of NOACs vs. warfarin in AF patients with cancer. Efficacy outcome measures included stroke or systemic embolism, venous thromboembolism and mortality. Safety outcome measures were major bleeding and intracranial hemorrhage. Results We pooled data from 6 identified studies enrolling a total of 31,756 AF patients with cancer. Mean follow-up was 1.7 years. Patients with cancer had significantly increased annualized rates of venous thromboembolism (1.38% vs. 0.74%), major bleeding (9.01% vs. 5.13%), in particular major gastrointestinal bleeding (2.38% vs. 1.60%), and all-cause mortality (17.73% vs. 8.50%) vs. those without (all P values <0.001), whereas the incidence of stroke or systemic embolism and intracranial hemorrhage did not differ. Compared with warfarin, treatment with NOACs nominally decreased the risk of stroke or systemic embolism (5.41% vs. 2.70%; odds ratio, OR; 95% confidence intervals, CI 0.51, 0.26–1.01; P=0.05; Figure), mainly of ischemic stroke (OR 0.56; 95% CI 0.35–0.89; P=0.01), and the risk of venous thromboembolism (OR 0.51; 95% CI 0.42–0.61; P<0.001). In cancer patients receiving NOACs there was a significant reduction of major bleeding (3.95% vs. 4.66%; OR 0.66, 95% CI 0.46–0.94; P=0.02; Figure) and intracranial hemorrhage (0.26% vs. 0.66%; OR 0.25, 95% CI 0.08–0.82; P=0.02) vs. warfarin, with no difference in gastrointestinal major bleeding rates. Conclusion AF patients on oral anticoagulation and concomitant cancer are at higher risk of venous thromboembolism, major bleeding and all-cause mortality. NOACs may represent a safer and more effective alternative to warfarin also in this setting of patients.

scholarly journals Clinical Outcomes of Concomitant Use of Proton Pump Inhibitors and Dual Antiplatelet Therapy: A Systematic Review and Meta-Analysis

2021 ◽  
Vol 12 ◽  
Author(s):  
Hongzhou Guo ◽  
Zhishuai Ye ◽  
Rongchong Huang
Keyword(s):  
Antiplatelet Therapy ◽  
Proton Pump Inhibitors ◽  
Proton Pump ◽  
Cardiovascular Events ◽  
Observational Studies ◽  
Dual Antiplatelet Therapy ◽  
Meta Analysis ◽  
Gi Bleeding ◽  
Coronary Syndrome ◽  
All Cause Mortality

Background: The safety and efficacy associated with the use of proton pump inhibitors (PPIs) by patients with coronary artery disease receiving dual antiplatelet therapy (DAPT) remain unclear.Methods: The evaluated outcomes included combined major adverse cardiovascular events (MACEs), myocardial infarction (MI), all-cause mortality, and gastrointestinal (GI) bleeding. A random effects meta-analysis, stratified by study design, was performed and heterogeneity was assessed using the I2 statistic.Results: In total, 6 randomized controlled trials (RCTs) (6930 patients) and 16 observational studies (183,546 patients) were included. Analysis of RCTs showed that there were no significant differences in the incidences of MACEs (risk ratio [RR] = 0.89 [95% confidence interval (CI) = 0.75–1.05]), MI (RR = 0.93 [95% CI = 0.76–1.15]), and all-cause mortality (RR = 0.79 [95% CI = 0.50–1.23]) in the PPI groups vs. the non-PPI groups. Pooled data from observational studies revealed an inconsistent association between the use of each PPI subtype and the increased risks of MACEs during clopidogrel treatment. There was no increased risk of MACEs or all-cause mortality associated with the use of PPIs (as a class) and other P2Y12 inhibitors. Both the RCTs and observational studies revealed that the use of PPIs significantly reduced the risks of GI bleeding.Conclusion: The use of PPIs was associated with a reduced risk of GI bleeding in patients treated with DAPT after percutaneous coronary intervention or acute coronary syndrome. There was no clear evidence of an association between the use of PPIs and adverse cardiovascular events.Clinical Trial Registration: identifier [CRD42020190315]

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