Benefit of dual antithrombotic therapy with direct oral anticoagulants in patients with atrial fibrillation undergoing p
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CE-SYSTEMATIC REVIEWS AND META-ANALYSIS
Benefit of dual antithrombotic therapy with direct oral anticoagulants in patients with atrial fibrillation undergoing percutaneous coronary intervention: a systematic review and metaanalysis of randomized clinical trials Giacomo Zoppellaro1 · Giuseppe Maria Marchese2 · Alessandro Squizzato3 · Gentian Denas4 · Giuseppe Patti5 · Raffaele De Caterina6 · Vittorio Pengo4 Received: 14 April 2020 / Accepted: 6 June 2020 © Società Italiana di Medicina Interna (SIMI) 2020
Abstract Antithrombotic treatment in patients with atrial fibrillation undergoing percutaneous coronary intervention is still debated. We conducted a meta-analysis of recent randomized controlled trials to evaluate the benefit of different antithrombotic strategies. Data were analyzed between May and September 2019. Efficacy outcomes were trial-defined major adverse cardiovascular events (MACE); its individual components; stent thrombosis. Safety outcomes were trial-defined primary bleeding outcome; TIMI and ISTH major bleeding; clinically relevant non-major bleeding; intracranial hemorrhage. Differences in outcomes among groups were expressed as pooled odds ratio (OR) and corresponding 95% confidence interval (CI). Four randomized studies were included (10,969 patients). The mean age ranged from 69 to 72 years, prevalence of acute coronary syndrome (ACS) varied from 48 to 62%. Comparing dual antithrombotic therapy (DAT) with a direct oral anticoagulant (DOAC) versus triple antithrombotic therapy (TAT) with vitamin K antagonist (VKA), OR for trial-defined MACE and primary bleeding outcome were 1.03 (95% CI, 0.86–1.24) and 0.59 (95% CI, 0.41–0.86), respectively. There was a 68% lower risk of intracranial hemorrhage and a non-statistically significant higher risk of stent thrombosis with DAT. DAT was as effective and safer than TAT in patients with stable coronary artery disease, while a trend towards increased ischemic events was seen in ACS patients. DAT with a DOAC showed similar efficacy and less bleeding than TAT with a VKA. However, increased stent thrombosis with DAT may be present, and TAT should be considered in patients at high ischemic risk, such as ACS patients. Keywords Direct oral anticoagulants · Dual and triple antithrombotic therapy · Atrial fibrillation · Percutaneous coronary intervention
Giacomo Zoppellaro and Giuseppe Maria Marchese have equally contributed to the work. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11739-020-02402-3) contains supplementary material, which is available to authorized users. * Giacomo Zoppellaro [email protected] 1
Ospedale Civile di Venezia, Azienda ULSS3 Serenissima, Venice, Italy
2
Ospedali Riuniti Padova Sud, Azienda ULSS 6 Euganea, Padua, Italy
3
Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese and Como, Italy
Introduction Atrial fibrillation (AF) is a major global health problem that increases
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