P2Y₁₂ inhibitors with oral anticoagulation for percutaneous coronary intervention with atrial fibrillation: a systematic review and meta-analysis

Abstract

ObjectiveThis study aimed to compare the safety and efficacy of third-generation P2Y12 inhibitors versus clopidogrel in combination with oral anticoagulation (OAC) with or without aspirin in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsWe performed a systematic review including both prospective and retrospective studies that compared dual and triple antithrombotic regimens for bleeding and major adverse cardiac events (MACE) in patients with AF undergoing PCI. We analysed rates of bleeding and MACE by P2Y12 inhibitor choice. Risk ratio (RR) 95% CIs were measured using the Mantel-Haenszel method. Where study heterogeneity was low (I2 <25%), we used the fixed effects model, otherwise the random effects model was used.ResultsA total of 22 014 patients were analysed from the seven studies included. Among patients treated with both OAC and P2Y12 inhibitor with or without aspirin, 90% (n=9708) were treated with clopidogrel, 8% (n=830) with ticagrelor, and 2% (n=191) with prasugrel. When compared with clopidogrel, use of ticagrelor (RR 1.36; 95% CI 1.18 to 1.57) and prasugrel (RR 2.11; 95% CI 1.34 to 3.30) were associated with increased rates of bleeding. Compared with clopidogrel, there were no significant differences in rates of MACE with ticagrelor (RR 1.03; 95% CI 0.65 to 1.62) or prasugrel (RR 1.49; 95% CI 0.69 to 3.24).ConclusionBased on this meta-analysis, the use of clopidogrel is associated with a lower rate of bleeding compared with ticagrelor or prasugrel in patients with AF on OAC undergoing PCI.

Ticagrelor: A Safe Option as Part of Triple Therapy?

“…19 In a meta-analysis of 22,014 patients on OAC undergoing PCI, use of clopidogrel was associated with a lower rate of bleeding compared with ticagrelor. 20 In another systematic review analyzing 5659 patients on DT or TT, the use of ticagrelor was associated with higher rates of clinically significant hemorrhage as compared with clopidogrel. 19 Thus, the risk of major intracranial bleeding is likely enhanced when ticagrelor is used as a part of TT, as it was in our patient who suffered a massive intracranial bleed.…”

Antithrombotic Management for Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention or With Acute Coronary Syndrome: An Evidence-Based Update

“…The experience of prasugrel use was also limited (1.3% in the PIONEER AF-PCI study, 1.1% in the AUGUSTUS study, <1% in the ENTRUST-AF PCI study, and 0% in the RE-DUAL PCI trial) ( 5 – 8 ). Particularly, data for ticagrelor or prasugrel as DAT or TAT seem discouraging due to the high bleeding rate compared with that observed with clopidogrel (ticagrelor: relative risk [RR] 1.36; 95% CI, 1.18–1.57 and prasugrel: RR 2.11; 95% CI, 1.34–3.30) ( 36 ), which suggests that powerful P2Y12 inhibitors may not be the first-line choice for use with OAC in AF patients after PCI. Because clopidogrel is characterized as providing less potent and variable platelet inhibition ( 37 ), more individualized and comprehensive antithrombotic strategies could be evaluated in future studies.…”

Safety and Efficacy of Triple Therapy With Ticagrelor or Prasugrel Versus Clopidogrel After Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

“…Recent systematic reviews and meta-analyses comparing the safety and efficacy of ticagrelor and/or prasugrel versus clopidogrel with OAC with or without aspirin in patients with AF undergoing PCI found increased rates of bleeding with ticagrelor and prasugrel and mixed results in rates of MACE compared to clopidogrel. 17,18 We sought to explore the utilization of these potent P2Y 12 inhibitors in STEMI, a population at high thrombotic risk.…”