Safety and efficacy of double vs. triple antithrombotic therapy in patients with atrial fibrillation with or without acute coronary syndrome undergoing percutaneous coronary intervention: a systematic review and meta-analysis of vitamin k antagonist a

  • Authors

    • Phav Sophearith Zhongnan Hospital Of Wuhan University
    2021-02-02
    https://doi.org/10.14419/ijm.v9i1.31369
  • Acute Coronary Syndrome, Atrial Fibrillation, Percutaneous Coronary Intervention, Double and Triple Antithrombic Therapy.
  • Objective: To compare the safety and efficacy of double therapy (DT) (no aspirin) versus triple therapy (TT) (with aspirin) antithrombotic drugs in patients with atrial fibrillation and acute coronary syndrome or underwent percutaneous coronary intervention (PCI).

    Methods: We searched PubMed, Cochrane, Scopus, and Web of Science for relevant articles from inception to December 2020. We conducted the analysis of dichotomous outcomes using risk ratio (RR) and relative 95% confidence interval (CI), while the continuous outcomes were analyzed using mean difference (MD) and relative 95% CI. Heterogeneous outcomes were analyzed with random-effects model, and homogeneous data were analyzed with fixed-effects model. We assessed the risk of bias among the included studies by using Cochrane’s risk of bias tool.

    Results: A total of five studies were included. Regarding Major or Minor Bleeding, the overall risk ratio was significantly lower with DT group compared with TT group (RR=0.60 [0.45, 0.81], (P = 0.07)). For the safety endpoint (TIMI major or minor bleeding, TIMI major bleeding) favored DT group over TT group, respectively (RR=0.60 [0.45, 0.81], (P = 0.07)); (RR= 0.55 [0.43, 0.70], (P < 0.01)). Intracranial hemorrhage did not differ between both groups (RR=0.62 [0.37, 1.05], (P = 0.07)). The efficacy endpoint, all-cause death showed no significant difference between both groups (RR=1.08 [0.89, 1.31], (P = 0.42)). There were no significant differences between two groups in cardiovascular death, stent thrombosis, myocardial infarction and stroke, respectively (RR=1.10 [0.86, 1.41], (P = 0.43); (RR=1.40 [0.92, 2.12], (P = 0.11); (RR=1.20 [0.98, 1.49], (P = 0.08); (RR=0.95 [0.66, 1.37], (P = 0.79).; respectively).

    Conclusion: Compared with triple antithrombotic therapy, double antithrombotic therapy is associated with lower bleeding risks, including minor and major bleeding, but the incidence of efficacy endpoints was similar between both groups.

     

     


     
  • References

    1. [1] Lip G, Huber K, Andreotti F, Arnesen H, Airaksinen KJ, Cuisset T, et al. Management of Antithrombotic Therapy in Atrial Fibrillation Patients Presenting with Acute Coronary Syndrome and/or Undergoing Percutaneous Coronary Intervention/ Stenting. Thromb Haemost. 2010; https://doi.org/10.1160/TH09-08-0580.

      [2] Hansen ML, Sørensen R, Clausen MT, Fog-Petersen ML, Raunsø J, Gadsbøll N, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010; https://doi.org/10.1001/archinternmed.2010.271.

      [3] Lamberts M, Olesen JB, Ruwald MH, Hansen CM, Karasoy D, Kristensen SL, et al. bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: A nationwide cohort study. Circulation. 2012; https://doi.org/10.1161/CIRCULATIONAHA.113.001654.

      [4] Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;

      [5] Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography a. J Am Coll Cardiol. 2011;

      [6] Stephan Windecker, Philippe Kolh, Fernando Alfonso, Jean-Philippe Collet, Jochen Cremer, Volkmar Falk, Gerasimos Filippatos, Christian Hamm, Stuart J. Head, Peter Jüni, A. Pieter Kappetein, Adnan Kastrati, Juhani Knuuti, Ulf Landmesser, Günther Laufer, Fr JD. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution . Eur Heart J. 2014;35(37):2541–619. https://doi.org/10.1093/eurheartj/ehu278.

      [7] Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;

      [8] Mega J, Carreras ET. Antithrombotic therapy: triple therapy or triple threat? Hematology / the Education Program of the American Society of Hematology. American Society of Hematology. Education Program. 2012. https://doi.org/10.1182/asheducation.V2012.1.547.3798919.

      [9] Sørensen R, Hansen ML, Abildstrom SZ, Hvelplund A, Andersson C, Jørgensen C, et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet. 2009; https://doi.org/10.1016/S0140-6736(09)61751-7.

      [10] Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med. 2009; https://doi.org/10.1056/NEJMoa0905561.

      [11] Dans AL, Connolly SJ, Wallentin L, Yang S, Nakamya J, Brueckmann M, et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the randomized evaluation of long-term anticoagulation therapy (RE-LY) trial. Circulation. 2013; https://doi.org/10.1161/CIRCULATIONAHA.112.115386.

      [12] Dewilde WJM, Oirbans T, Verheugt FWA, Kelder JC, De Smet BJGL, Herrman JP, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: An open-label, randomised, controlled trial. Lancet. 2013; 381(9872):1107–15. https://doi.org/10.1016/S0140-6736(12)62177-1.

      [13] Hurlen M, Abdelnoor M, Smith P, Erikssen J, Arnesen H. Warfarin, Aspirin, or Both after Myocardial Infarction. N Engl J Med. 2002; https://doi.org/10.1056/NEJMoa020496.

      [14] Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, et al. Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation. N Engl J Med. 2017; 377(16):1513–24. https://doi.org/10.1056/NEJMoa1708454.

      [15] Moher D, Liberati A, Tetzlaff J, Altman DG, Altman D, Antes G, et al. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement (Chinese edition). J Chinese Integr Med. 2009; 7(9):889–96. https://doi.org/10.3736/jcim20090918.

      [16] Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions: Cochrane Book Series. Vol. Version 5. 2008. 1 p. https://doi.org/10.1002/9780470712184.

      [17] Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. British Medical Journal. 2003. https://doi.org/10.1136/bmj.327.7414.557.

      [18] Higgins JP, Altman DG. Assessing Risk of Bias in Included Studies. In: Cochrane Handbook for Systematic Reviews of Interventions: Cochrane Book Series. 2008.

      [19] Kerneis M, Gibson CM, Chi G, Mehran R, AlKhalfan F, Talib U, et al. Effect of Procedure and Coronary Lesion Characteristics on Clinical Outcomes Among Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: Insights From the PIONEER AF-PCI Trial. JACC Cardiovasc Interv. 2018; 11(7):626–34. https://doi.org/10.1016/j.jcin.2017.11.009.

      [20] Lopes RD, Leonardi S, Wojdyla DM, Vora AN, Thomas L, Storey RF, et al. Stent thrombosis in patients with atrial fibrillation undergoing coronary stenting in the augustus trial. Circulation. 2020; 781–3. https://doi.org/10.1161/CIRCULATIONAHA.119.044584.

      [21] Vranckx P, Valgimigli M, Eckardt L, Tijssen J, Lewalter T, Gargiulo G, et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet. 2019; 394(10206):1335–43. https://doi.org/10.1016/S0140-6736(19)31872-0.

      [22] Higgins J, Altman D. Assessing risk of bias. In: Cochrane Handbook for Systematic Reviews of Interventions: Cochrane Book Series. 2008. https://doi.org/10.1002/9780470712184.

      [23] Lanas A, Scheiman J. Low-dose aspirin and upper gastrointestinal damage: Epidemiology, prevention and treatment. Current Medical Research and Opinion. 2007. https://doi.org/10.1185/030079907X162656.

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    Sophearith, P. (2021). Safety and efficacy of double vs. triple antithrombotic therapy in patients with atrial fibrillation with or without acute coronary syndrome undergoing percutaneous coronary intervention: a systematic review and meta-analysis of vitamin k antagonist a. International Journal of Medicine, 9(1), 10-17. https://doi.org/10.14419/ijm.v9i1.31369