DUAL ANTITHROMBOTIC THERAPY IS SAFE AND EFFECTIVE IN PATIENTS WITH ATRIAL FIBRILLATION UNDERGOING PCI: UPDATED SYSTEMATIC REVIEW AND META-ANALYSIS
CCC ePoster Library. Bakar S. 10/26/19; 280315; 257
Shahrukh Bakar
Shahrukh Bakar
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Abstract
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BACKGROUND: Optimal antithrombotic therapy regimen in patients with atrial fibrillation (AF), presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI) is unclear.

METHODS AND RESULTS: We performed a systematic review and meta-analysis to evaluate the safety and efficacy of dual versus triple antithrombotic therapy. MEDLINE, EMBASE, and Web of Science were systematically searched. All randomized trials of dual versus triple antithrombotic therapy were included. The primary safety and efficacy outcomes were Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding and myocardial infarction (MI), respectively. Secondary outcomes included stent thrombosis, stroke, trial-defined major adverse cardiac events (MACE) and cardiac death. Bayesian network meta-analyses and subgroup analyses were pre-specified. Hazard ratios (HR, 95%CI) were calculated using random-effects model. Five trials involving 9,961 patients were included (73% male; mean age 71 years). Compared to triple antithrombotic therapy (TAT), dual antithrombotic therapy (DAT) resulted in a 48% reduction in TIMI major or minor bleeding (4.0% vs. 7.7%, HR 0.52, 95%CI 0.42-0.65, I2= 22%, p < 0.001). There were no significant differences in ischemic outcomes of MI (3.4 % vs. 2.9%, HR 1.14, 0.90-1.45, I2= 0%, p=0.27), stent thrombosis (0.98% vs. 0.70%, HR 1.26, 0.69-2.29), stroke (1.1% vs. 1.1%, HR 0.93, 0.62-1.40), trial-defined MACE (9.1% vs. 8.2%, HR 0.94, 0.74-1.19), or cardiac death (2.6% vs. 2.4%, HR 1.00, 0.74-1.34). Network meta-analysis pairwise comparisons for TIMI major or minor bleeding showed significantly lower bleeding with DAT-NOAC compared to TAT-VKA (OR 0.43, 95% CrI 0.21-0.91). Subgroup analyses showed that trial-specified bleeding was significantly lower for dual antithrombotic therapy compared to triple antithrombotic therapy regardless of age (interaction p-value=0.21), sex (p=0.32), ACS or elective indication for PCI (p=0.75), and presence of diabetes (p=0.38).

CONCLUSION: Compared to triple therapy, dual antithrombotic therapy resulted in reduced bleeding without a significant increase in ischemic events. Current evidence supports the use of dual antithrombotic therapy over triple therapy for patients with AF following PCI.
BACKGROUND: Optimal antithrombotic therapy regimen in patients with atrial fibrillation (AF), presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI) is unclear.

METHODS AND RESULTS: We performed a systematic review and meta-analysis to evaluate the safety and efficacy of dual versus triple antithrombotic therapy. MEDLINE, EMBASE, and Web of Science were systematically searched. All randomized trials of dual versus triple antithrombotic therapy were included. The primary safety and efficacy outcomes were Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding and myocardial infarction (MI), respectively. Secondary outcomes included stent thrombosis, stroke, trial-defined major adverse cardiac events (MACE) and cardiac death. Bayesian network meta-analyses and subgroup analyses were pre-specified. Hazard ratios (HR, 95%CI) were calculated using random-effects model. Five trials involving 9,961 patients were included (73% male; mean age 71 years). Compared to triple antithrombotic therapy (TAT), dual antithrombotic therapy (DAT) resulted in a 48% reduction in TIMI major or minor bleeding (4.0% vs. 7.7%, HR 0.52, 95%CI 0.42-0.65, I2= 22%, p < 0.001). There were no significant differences in ischemic outcomes of MI (3.4 % vs. 2.9%, HR 1.14, 0.90-1.45, I2= 0%, p=0.27), stent thrombosis (0.98% vs. 0.70%, HR 1.26, 0.69-2.29), stroke (1.1% vs. 1.1%, HR 0.93, 0.62-1.40), trial-defined MACE (9.1% vs. 8.2%, HR 0.94, 0.74-1.19), or cardiac death (2.6% vs. 2.4%, HR 1.00, 0.74-1.34). Network meta-analysis pairwise comparisons for TIMI major or minor bleeding showed significantly lower bleeding with DAT-NOAC compared to TAT-VKA (OR 0.43, 95% CrI 0.21-0.91). Subgroup analyses showed that trial-specified bleeding was significantly lower for dual antithrombotic therapy compared to triple antithrombotic therapy regardless of age (interaction p-value=0.21), sex (p=0.32), ACS or elective indication for PCI (p=0.75), and presence of diabetes (p=0.38).

CONCLUSION: Compared to triple therapy, dual antithrombotic therapy resulted in reduced bleeding without a significant increase in ischemic events. Current evidence supports the use of dual antithrombotic therapy over triple therapy for patients with AF following PCI.
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