Outcomes of dual antiplatelet therapy in combination with direct oral anticoagulants in patients with acute coronary syndrome: a meta-analysis

Abstract

Abstract Background Recent data showed that the use of direct oral anticoagulants (DOAC) in addition to dual antiplatelet therapy (DAPT) is associated with reduced risk of adverse cardiovascular (CV) outcomes in patients with acute coronary syndrome (ACS) with or without percutaneous coronary intervention (PCI), but It has also been associated with increased risk of bleeding. The data differs among different studies, thus, the CV outcomes associated with use of DOAC therapy plus DAPT are not fully understood. We conducted a meta-analysis to explore the CV and bleeding outcomes of DOAC therapy plus DAPT vs DAPT with or without placebo in patients with ACS Methods We conducted a literature search of studies exploring the use of DAPT plus DOAC therapy with focusing on bleeding and CV outcomes including myocardial infarction (MI), stroke, stent thrombosis, limb thrombosis and VTE using Ovid, Scopus, PubMed, Medline, and EBSCO databases from January 2010 to March 2020. We used the following terms for the literature search: (Aspirin AND Clopidogrel OR Prasugrel OR Ticagrelor) AND (Apixaban OR Rivaroxaban OR Edoxaban OR Dabigatran OR Betrixaban). The efficacy outcome was a composite of CV death, MI and stroke, and the safety outcome was major bleeding. Results 4857 articles were included. Only RCTs and RCTs post-hoc analysis, were included (N=3). We found no significant heterogeneity and lower odds of the efficacy outcome in DOAC plus DAPT (experimental arm) compared to DAPT plus placebo (Control arm), which were unchanged in both the fixed and random effect models (Odds Ratio [OR] 0.87, 95% Confidence Interval [CI]: 0.78–0.97, I2=0%). We found no significant heterogeneity and higher odds of the safety outcome in DOAC plus DAPT (experimental arm) compared to DAPT plus placebo (Control arm) (OR fixed model 3.27, 95% CI: 2.28–4.70; OR random model 3.18, 95% CI: 2.21–4.57; I2=0%). Conclusion DOAC therapy plus DAPT in patients with ACS with or without PCI was associated with a lower rate of CV death, MI and stroke when compared to DAPT alone or with placebo and also associated with significant increase in major bleeding Funding Acknowledgement Type of funding sources: None.