Abstract
Up to 10% of patients with atrial fibrillation (AF) undergo percutaneous coronary intervention (PCI). A systematic review and network meta-analysis were conducted by searching PubMed, Embase, and the Cochrane database of systematic reviews for randomized control trials that studied the safety and efficacy of different antithrombotic strategies in these patients. Six studies, including 12,158 patients were included. Compared to that in the triple antithrombotic therapy group (vitamin K antagonist (VKA) plus P2Y12 inhibitor and aspirin), thrombolysis in myocardial infarction (TIMI) major bleeding was significantly reduced in the dual antithrombotic therapy (non-vitamin K oral anticoagulants (NOACs) plus P2Y12 inhibitor) group by 47% (Odds ratio (OR), 0.53; 95% credible interval [CrI], 0.35–0.78; I2 = 0%). Besides, NOAC plus a P2Y12 inhibitor was associated with less intracranial hemorrhage compared to VKA plus single antiplatelet therapy (OR: 0.20, 95% CrI: 0.05–0.77). There was no significant difference in the trial-defined major adverse cardiac events or the individual outcomes of all-cause mortality, cardiovascular death, myocardial infarction, stroke or stent thrombosis among all antithrombotic strategies. In conclusion, antithrombotic strategy of NOACs plus P2Y12 inhibitor is safer than, and as effective as, the strategies including aspirin when used in AF patients undergoing PCI.
Highlights
Up to 30% of patients with atrial fibrillation (AF) have concomitant coronary artery disease (CAD) and approximately 10% of them undergo percutaneous coronary intervention (PCI) [1]
Current guidelines for AF patients undergoing PCI recommend using triple thrombotic therapy, which is a combination of Vitamin K antagonists (VKAs) or non-vitamin K oral anticoagulants (NOACs) with dual antiplatelet therapy (DAPT) to reduce the risk of cardioembolic and coronary thrombotic complications [4,5]
Several meta-analyses have concluded that administering dual antithrombotic therapy with NOAC and P2Y12 inhibitors results in fewer major bleeding events, but similar efficacy compared to triple therapy, including VKA or NOAC with DAPT [13,14,15]
Summary
Up to 30% of patients with atrial fibrillation (AF) have concomitant coronary artery disease (CAD) and approximately 10% of them undergo percutaneous coronary intervention (PCI) [1]. Several meta-analyses have concluded that administering dual antithrombotic therapy with NOAC and P2Y12 inhibitors results in fewer major bleeding events, but similar efficacy compared to triple therapy, including VKA or NOAC with DAPT [13,14,15] Most of these meta-analyses did not include the latest reported edoxaban-based antithrombotic regimen in patients with AF following the successful percutaneous coronary intervention (ENTRUST-AF PCI) trial, which was found to be insufficient to detect differences in safety outcome between the antithrombotic strategies with and without aspirin in such patients [16].
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