Network meta-analysis and trial sequential analysis for atrial fibrillation patients receiving PCI or with ACS

Abstract

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (aspirin) and a P2Y 12 antagonist is recommended for patients undergoing percutaneous coronary intervention (PCI), mainly to prevent stent thrombosis, and for acute coronary syndrome (ACS) patients, mostly to prevent recurrent events. 1 For patients with atrial fibrillation (AF), oral anticoagulation therapy is required to decrease the risk of stroke or systemic embolism. 2 In daily practice, patients with concomitant coronary artery disease and AF are frequently encountered, since 30% of patients with AF also have coronary artery disease, 10%-15% of patients with AF receive PCI, and up to 15% of patients with stable coronary artery disease have concomitant AF. 3 This raises concerns regarding the cotreatment with various antithrombotic and antiplatelet drugs, given that a high risk of bleeding is associated with DAPT in combination with oral anticoagulation therapy (triple antithrombotic therapy [TAT]), especially in patients with AF who receive PCI or who have ACS. 4 Several systematic reviews with meta-analysis based on evidence from randomized controlled trials (RCTs) [5][6][7][8] have been conducted to address this issue. 3,[9][10][11] All these systematic reviews have led to similar conclusions: that omitting aspirin resulted in fewer major bleeds, while preserving the efficacy of therapy, compared with TAT (combining a vitamin K antagonist [VKA] or novel oral anticoagulant [NOAC] with DAPT). Moreover, the use of NOAC + P2Y 12 inhibitor was recommended as the preferred regimen after PCI for these high-risk patients with AF. 9 Although the summarized bleeding risk of these meta-analyses