Abstract
The optimal antithrombotic regimen for patients with atrial fibrillation and ischemic heart disease remains unclear. Therefore, we aimed to compare the efficacy and safety of triple therapy (TT [an anticoagulant and 2 antiplatelet drugs]) with dual therapy (DAPT [2 antiplatelet drugs] or DT [an anticoagulant and a single antiplatelet drug]) in patients with atrial fibrillation and ischemic heart disease. We systematically searched the Cochrane Library, PubMed and Embase databases for all relevant studies up to August 2017. The overall risk estimates were calculated using the random-effects model. A total of 17 observational studies were included. Regarding the efficacy outcomes, no differences were observed between the triple therapy and the dual therapy for all-cause death, cardiovascular death, or thrombotic complications (i.e., acute coronary syndrome, stent thrombosis, thromboembolism/stroke, and major adverse cardiac and cerebrovascular events). Regarding the safety outcomes, compared with DAPT, TT was associated with increased risks of major bleeding (a relative risk of 1.96 [1.40–2.74]), minor bleeding (1.69 [1.06–2.71]) and overall bleeding (1.80 [1.23–2.64]). Compared wtih DT, TT was associated with a greater risk of major bleeding (1.65 [1.23–2.21]), but rates of minor bleeding (0.99 [0.56–1.77]) and overall bleeding (1.14 [0.76–1.71]) were similar. Overall, TT confers an increased hazard of major bleeding with no thromboembolic protection compared with dual therapy in patients with atrial fibrillation and ischemic heart disease.
Highlights
20–30% of atrial fibrillation (AF) patients have coexisting ischemic heart disease (IHD) [1]
TT confers an increased hazard of major bleeding with no thromboembolic protection compared with dual therapy in patients with atrial fibrillation and ischemic heart disease
Twenty-seven of those studies were excluded for the following reasons: (1) they were studies that included IHD patients both with and without AF (n = 12) [16,17,18,19,20,21,22,23,24,25,26,27] or studies including AF patients with and without IHD (n = 1) [28]; and (2) the studies had insufficient data (n = 9; 5 studies did not compare the outcomes of triple therapy with those of dual therapy [29,30,31,32,33], 2 studies did not report the outcomes of interest [34, 35], and 2 studies did not report the risk estimates [36, 37]), duplicate data (n = 3) [38,39,40] or follow up data of less than 1 year (n = 2) [41, 42]
Summary
20–30% of atrial fibrillation (AF) patients have coexisting ischemic heart disease (IHD) [1]. Dual antithrombotic therapy was found to decrease the risk of major adverse cardiac events in a large study of patients with AF and IHD [9] but did not decrease the risk of coronary death or myocardial infarction (MI) in another study [10]. In this meta-analysis, we aimed to compare the efficacy and safety of TT with those of dual therapies (DAPT or DT) in patients with AF and IHD
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