Highlights
- •Optimization of antithrombotic therapy in AF patients undergoing PCI is challenging.
- •Traditional triple therapy is associated with an excess risk of major bleeding events.
- •Recent RCTs showed a reduced risk of bleeding linked to DT.
- •Meta-analysis of RCTs arises the possibility of an increased risk of ST following DT.
- •DOACs is a valuable option, maintaining aspirin in higher thrombotic risk.
Abstract
Background
The management of antithrombotic therapy in patients undergoing percutaneous coronary
intervention (PCI) with an indication for long-term oral anticoagulant therapy (OAT)
is still a matter of debate. We aim to evaluate the safety and the efficacy of dual
therapy (DT) compared to triple therapy (TT) in this clinical setting.
Methods
A study level meta-analysis and a review of randomized trials selected using PubMed,
Embase, EBSCO, Cochrane database of systematic reviews, Web of Science, and abstract
from major cardiology congresses. Six randomized trials with 12,156 patients evaluating
the strategy of DT vs. TT in patients treated with PCI with indication for long-term
OAT were included.
Results
Patients treated with DT demonstrated a 45% relative reduction in the risk of TIMI
major bleeding (1.71% vs. 2.99%; OR 0.55, 95% CI 0.41–0.71; P<0.0001) and TIMI minor bleeding compared to TT arm (4.67% vs 7.83%, OR 0.55 95% CI
0.39–0.78, P = 0.0007). All-cause mortality was similar in two arms (3.95% vs 3.77%, P = 0.92), as well as cardiovascular mortality (2.21% vs 2.19%, P = 0.97). DT was associated with a borderline increase of ST (1.02% vs 0.67%, P = 0.07). No significant differences were observed in occurrence of MI and stroke.
Conclusions
Our findings suggest that DT is safer than TT with regard to occurrence of major bleeding.
DT with a direct oral anticoagulant plus clopidogrel at discharge could be effective
in most patients, maintaining aspirin in periprocedural phase and as longer “tailored”
treatment for patients at higher ischemic risk.
Keywords
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Article info
Publication history
Published online: February 13, 2020
Accepted:
February 3,
2020
Received in revised form:
January 30,
2020
Received:
November 2,
2019
Identification
Copyright
© 2020 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
