Antithrombotic Regimens for Patients Taking Oral Anticoagulation After Coronary Intervention: A Meta‐analysis of 16 Clinical Trials and 9185 Patients

Abstract

The optimal antithrombotic regimen remains controversial in patients taking oral anticoagulation (OAC) undergoing coronary stenting. This study sought to compare efficacy and safety outcomes of triple therapy (OAC, aspirin, and clopidogrel) vs dual therapy (clopidogrel with aspirin or OAC) in these patients. We hypothesize OAC plus clopidogrel could be the optimal regimen for patients with indications for OAC receiving stent implantation. Medline, the Cochrane Library, and other Internet sources were searched for clinical trials comparing the efficacy and safety of triple vs dual therapy for patients taking OAC after coronary stenting. Sixteen eligible trials including 9185 patients were identified. The risks of major adverse cardiac events (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 0.82‐1.39, P = 0.65), all‐cause mortality (OR: 0.98, 95% CI: 0.76‐1.27, P = 0.89), myocardial infarction (OR: 1.01, 95% CI: 0.77‐1.31, P = 0.97), and stent thrombosis (OR: 0.91, 95% CI: 0.49‐1.69, P = 0.75) were similar between triple and dual therapy. Compared with dual therapy, triple therapy was associated with a reduced risk of ischemic stroke (OR: 0.57, 95% CI: 0.35‐0.94, P = 0.03) but with higher major bleeding (OR: 1.52, 95% CI: 1.11‐2.10, P = 0.01) and minor bleeding (OR: 1.59, 95% CI: 1.05‐2.42, P = 0.03). Subgroup analysis indicated there were similar ischemic stroke and major bleeding outcomes between triple therapy and therapy with OAC plus clopidogrel. Treatment with OAC and clopidogrel was associated with similar efficacy and safety outcomes compared with triple therapy. Triple therapy could be replaced by OAC plus clopidogrel without any concern about additional risk of thrombotic events.

Incidence and Predictors of Left Ventricular Thrombus After Primary Percutaneous Coronary Intervention for Anterior ST‐Segment Elevation Myocardial Infarction

“…The use of clopidogrel as a single antiplatelet agent with warfarin after coronary stenting was compared with triple therapy, and although bleeding was reduced and no difference in ischemic outcomes was observed, the safety of this strategy is still debatable . A recent meta‐analysis from Gao et al reaffirms the risk of triple therapy and that alternative therapeutic regimens in PCI patients requiring oral anticoagulation may reduce bleeding without compromising safety …”

“…There is, however, limited data supporting the routine prophylactic use of warfarin following anterior myocardial infarction (MI) complicated by LV dysfunction. Furthermore, concomitant warfarin and dual antiplatelet therapy (DAPT) is associated with a high risk of major bleeding . The 2013 American College of Cardiology/American Heart Association Guidelines, therefore, assigns a class IIb recommendation for the prophylactic use of warfarin in patients with STEMI and anterior apical akinesis or dyskinesis .…”

“…antiplatelet therapy (DAPT) is associated with a high risk of major bleeding. 3,4 The 2013 American College of Cardiology/American Heart Association Guidelines, therefore, assigns a class IIb recommendation for the prophylactic use of warfarin in patients with STEMI and anterior apical akinesis or dyskinesis. 5 However, there is limited data on identification of subsets of patients who may experience a net benefit from warfarin following anterior MI.…”

Triple Antithrombotic Therapy in Atrial Fibrillation Patients With an Indication for Oral Anticoagulation Undergoing Percutaneous Coronary Intervention

“…An individual patient-centered approach is preferred, as suggested in the European consensus document. 6 Nevertheless, in light of the findings from WOEST and registry data, 29 there seems to be an increasing amount of data supporting the use of dual therapy and OAC in selected AF patients rather than TT after PCI.…”

Clinical Outcomes of Antithrombotic Strategies for Patients with Atrial Fibrillation After Percutaneous Coronary Intervention

“…1,2) It has been confirmed that dual antiplatelet therapy (DAPT), including aspirin and a P2Y12 inhibitor, is not a good choice for these patients due to increased risk of ischaemic stroke and embolism complications. 3,4) Traditional triple therapy (vitamin K antagonist [VKA] + DAPT), which is recommended by current guidelines, 5,6) is associated with reduced ischaemic events but at the cost of the unacceptable risk of major bleeding. 3,4,7) Hence, VKA plus single antiplatelet therapy (SAPT), such as aspirin or clopidogrel, is also recommended to reduce the bleeding risk.…”