Antithrombotic therapy strategies for atrial fibrillation patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis

Gong, Xiaoxuan; Tang, Shaowen; Li, Jiangjin; Zhang, Xiwen; Tian, Xin; Ma, Shuren

doi:10.1371/journal.pone.0186449

Cited by 10 publications

(5 citation statements)

References 38 publications

(28 reference statements)

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“…A prior NMA investigated antithrombotic strategies in patients with AF and ACS and/or PCI. The authors found that the combination of VKA and a single antiplatelet agent provided the best choice in terms of safety and efficacy, with a very low dose of rivaroxaban, 2.5 mg, twice daily plus DAPT as an acceptable alternative.…”

Section: Discussionmentioning

confidence: 99%

Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

et al. 2019

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The antithrombotic treatment of patients with atrial fibrillation (AF) and coronary artery disease, in particular with acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI), poses a significant treatment dilemma in clinical practice.OBJECTIVE To study the safety and efficacy of different antithrombotic regimens using a network meta-analysis of randomized controlled trials in this population.DATA SOURCES PubMed, EMBASE, EBSCO, and Cochrane databases were searched to identify randomized controlled trials comparing antithrombotic regimens.STUDY SELECTION Four randomized studies were included (n = 10 026; WOEST, PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS). DATA EXTRACTION AND SYNTHESISThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review and network meta-analysis between 4 regimens using a Bayesian random-effects model. A pre hoc statistical analysis plan was written, and the review protocol was registered at PROSPERO. Data were analyzed between November 2018 and February 2019. MAIN OUTCOMES AND MEASURESThe primary safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding; secondary safety outcomes were combined TIMI major and minor bleeding, trial-defined primary bleeding events, intracranial hemorrhage, and hospitalization. The primary efficacy outcome was trial-defined major adverse cardiovascular events (MACE); secondary efficacy outcomes were individual components of MACE. RESULTSThe overall prevalence of ACS varied from 28% to 61%. The mean age ranged from 70 to 72 years; 20% to 29% of the trial population were women; and most patients were at high risk for thromboembolic and bleeding events. Compared with a regimen of vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT; P2Y 12 inhibitor plus aspirin), the odds ratios (ORs) for TIMI major bleeding were 0.58 (95% CI, 0.31-1.08) for VKA plus P2Y 12 inhibitor, 0.49 (95% CI, 0.30-0.82) for non-VKA oral anticoagulant (NOAC) plus P2Y 12 inhibitor, and 0.70 (95% CI, 0.38-1.23) for NOAC plus DAPT. Compared with VKA plus DAPT, the ORs for MACE were 0.96 (95% CI, 0.60-1.46) for VKA plus P2Y 12 inhibitor, 1.02 (95% CI, 0.71-1.47) for NOAC plus P2Y 12 inhibitor, and 0.94 (95% CI, 0.60-1.45) for NOAC plus DAPT. CONCLUSIONS AND RELEVANCEA regimen of NOACs plus P2Y 12 inhibitor was associated with less bleeding compared with VKAs plus DAPT. Strategies omitting aspirin caused less bleeding, including intracranial bleeding, without significant difference in MACE, compared with strategies including aspirin. Our results support the use of NOAC plus P2Y 12 inhibitor as the preferred regimen post-percutaneous coronary intervention for these high-risk patients with AF. A regimen of VKA plus DAPT should generally be avoided.

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Section: Discussionmentioning

confidence: 99%

Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

et al. 2019

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“…AF: atrial fibrillation trial-like strategy was chosen, which is also supported by a meta-analysis that suggests that a combination of vitamin K antagonists and single antiplatelet therapy is the best choice for AF patients undergoing percutaneous coronary intervention (PCI) considering both efficacy and safety. 16,17 Stenestrand et al 18 and Lopes et al 15 showed that only a small percentage of patients with AF and acute MI received oral anticoagulation therapy at discharge (30% and 43.4%, respectively).…”

Section: Discussionmentioning

confidence: 99%

New-Onset Atrial Fibrillation in St-Segment Elevation Myocardial Infarction: Predictors and Impact on Therapy And Mortality

Congo¹,

Belo

Carvalho³

et al. 2019

Arquivos Brasileiros De Cardiologia

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Backgrund: New-onset atrial fibrillation complicating acute myocardial infarction represents an important challenge, with prognostic significance.Objective: To study the incidence, impact on therapy and mortality, and to identify predictors of development of new-onset atrial fibrillation during hospital stay for ST-segment elevation myocardial infarction.Methods: We studied all patients with ST-elevation myocardial infarction included consecutively, between 2010 and 2017, in a Portuguese national registry and compared two groups: 1 -no atrial fibrillation and 2 -new-onset atrial fibrillation. We adjusted a logistic regression model data analysis to assess the impact of new-onset atrial fibrillation on in-hospital mortality and to identify independent predictors of its development. A p value < 0.05 was considered significant.Results: We studied 6325 patients, and new-onset atrial fibrillation was found in 365 (5.8%). Reperfusion was successfully accomplished in both groups with no difference regarding type of reperfusion. In group 2, therapy with beta-blockers and angiotensin-conversion enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) was less frequent, 20.6% received anticoagulation at discharge and 16.1% were on triple therapy. New-onset atrial fibrillation was associated with more in-hospital complications and mortality. However, it was not found as an independent predictor of in-hospital mortality. We identified age, prior stroke, inferior myocardial infarction and complete atrioventricular block as independent predictors of new-onset atrial fibrillation. Conclusion: New-onset atrial fibrillation remains a frequent complication of myocardial infarction and is associated with higher rate of complications and in-hospital mortality. Age, prior stroke, inferior myocardial infarction and complete atrioventricular block were independent predictors of new onset atrial fibrillation. Only 36.7% of the patients received anticoagulation at discharge.

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“…In this situation, a strategy based on NOACs was associated with a reduced risk of major bleeding events 51,52 . However, a network meta-analysis concluded that the best treatment strategy for these high-risk patients still appears to be the use of a VKA and single antiplatelet drugs when considering both efficacy and safety, even though the use of low-dose rivaroxaban appears as a valid alternative 53 .…”

Section: Summary and Discussionmentioning

confidence: 99%

Stroke Prevention, Evaluation of Bleeding Risk, and Anticoagulant Treatment Management in Atrial Fibrillation Contemporary International Guidelines

Proietti

Lane

Boriani

et al. 2019

Canadian Journal of Cardiology

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Antithrombotic therapy strategies for atrial fibrillation patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis

Cited by 10 publications

References 38 publications

Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

New-Onset Atrial Fibrillation in St-Segment Elevation Myocardial Infarction: Predictors and Impact on Therapy And Mortality

Stroke Prevention, Evaluation of Bleeding Risk, and Anticoagulant Treatment Management in Atrial Fibrillation Contemporary International Guidelines

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