Antithrombotic Strategies in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention: A Systemic Review and Network Meta-Analysis of Randomized Controlled Trials

Abstract

Up to 10% of patients with atrial fibrillation (AF) undergo percutaneous coronary intervention (PCI). A systematic review and network meta-analysis were conducted by searching PubMed, Embase, and the Cochrane database of systematic reviews for randomized control trials that studied the safety and efficacy of different antithrombotic strategies in these patients. Six studies, including 12,158 patients were included. Compared to that in the triple antithrombotic therapy group (vitamin K antagonist (VKA) plus P2Y12 inhibitor and aspirin), thrombolysis in myocardial infarction (TIMI) major bleeding was significantly reduced in the dual antithrombotic therapy (non-vitamin K oral anticoagulants (NOACs) plus P2Y12 inhibitor) group by 47% (Odds ratio (OR), 0.53; 95% credible interval [CrI], 0.35–0.78; I2 = 0%). Besides, NOAC plus a P2Y12 inhibitor was associated with less intracranial hemorrhage compared to VKA plus single antiplatelet therapy (OR: 0.20, 95% CrI: 0.05–0.77). There was no significant difference in the trial-defined major adverse cardiac events or the individual outcomes of all-cause mortality, cardiovascular death, myocardial infarction, stroke or stent thrombosis among all antithrombotic strategies. In conclusion, antithrombotic strategy of NOACs plus P2Y12 inhibitor is safer than, and as effective as, the strategies including aspirin when used in AF patients undergoing PCI.

Safety and Efficacy of Oral Anticoagulants Therapies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Network Meta-Analysis

“…Although some differences among studies exist especially given the different included trials and selected outcomes, overall evidence demonstrates that dual therapy with an DOAC and P2Y12 inhibitor is superior to triple therapy. 10 The gradual introduction over the past decade of the DOACs to be used in different cardiovascular conditions aimed for a more convenient and fixed-dose regimen compared to previous therapies. New oral anticoagulants have many theoretical advantages over warfarin, including comparable or superior efficacy in trial populations (eg, in AF, reduced risk of stroke, thromboembolism, an all-cause mortality) and reduced monitoring requirements.…”

“…New oral anticoagulants have many theoretical advantages over warfarin, including comparable or superior efficacy in trial populations (eg, in AF, reduced risk of stroke, thromboembolism, an all-cause mortality) and reduced monitoring requirements. [38][39][40][41][42] Five main RCTs comparing the use of different regimens of DOAC plus P2Y12 inhibitor in patients with AF undergoing PCI have been performed, and were included in both NMAs published by Lopes et al and Chua et al [10][11][12] Additionally, Chua et al included the ISAR-TRILPE trial (2015) 43 which evaluates whether shortening the duration of clopidogrel therapy (from 6 months to 6 weeks) after stent implantation was associated with a superior clinical outcome in patients receiving concomitant aspirin and OAC. The results of this trial demonstrated no significant differences on the duration of triple therapy with respect to net clinical outcomes.…”

“…This may occur because of the different included studies and definitions of safety outcomes. 10 To date, network meta-analyses (NMA), combining both direct and indirect evidence, were published by Lopes et al including 4 randomized controlled trials (RCT), recently updated with a fifth study, and by Chua et al with 6 RCT. These studies evaluated antithrombotic strategies for post-PCI in high-risk patients with AF, and concluded that the combination DOACs plus a P2Y12 inhibitor is a preferable alternative for these patients.…”

“…These studies evaluated antithrombotic strategies for post-PCI in high-risk patients with AF, and concluded that the combination DOACs plus a P2Y12 inhibitor is a preferable alternative for these patients. [10][11][12] However, both NMAs avoided comparing between the different DOACs. Thus, we aimed to synthetize the evidence on the individual effect of different antithrombotic therapies for patients with AF undergoing PCI through a systematic review with NMA, and to quantitatively evaluate the benefit-risk ratio of each regimen by means of stochastic multicriteria acceptability analysis (SMAA).…”

Cross-Cultural Translation into Brazilian Portuguese and Validation of the Oral Anticoagulation Knowledge Tool (AKT-Br)

“…Oral anticoagulant therapies (OAC), which are broadly classified into vitamin K antagonists (VKA) and direct oral anticoagulants (DOAC), are highly effective for the management of thromboembolic disorders; their use reduces the risk of stroke and systemic embolism by around two thirds [ 5 , 6 ] . However, these therapies are considered high-risk medications.…”