"Triple therapy" rather than "triple threat": a meta-analysis of the two antithrombotic regimens after stent implantation in patients receiving long-term oral anticoagulant treatment

Abstract

Background: An increasing number of patients with an indication for long-term oral anticoagulation (OAC) have undergone percutaneous coronary intervention with stent implantation (PCI-s). However, the optimal antithrombotic treatment for these patients is currently unknown. The purpose of this study was to characterize the benefits and risks of triple antithrombotic therapy (combined aspirin, clopidogrel, and OAC) after stent implantation in patients under long-term OAC treatment compared with dual antiplatelet therapy (combined aspirin and clopidogrel).

Methods: The study consisted of clinical controlled trials with ≥ 3 months of follow-up that compared triple antithrombotic therapy with dual antiplatelet therapy after stent implantation in patients undergoing long-term OAC treatment.

Results: Nine clinical trials included 1,996 participants. The meta-analysis was feasible because the grouping criterion was similar. The meta-analysis of the prevention of a major adverse cardiovascular event shows triple antithrombotic therapy to be more efficacious than dual antiplatelet therapy (OR, 0.60; 95% CI, 0.42-0.86; P = .005). There was a significant reduction in all-cause mortality with triple antithrombotic therapy compared with dual antiplatelet therapy. The meta-analysis of major bleeding in the first 6 months during follow-up shows significantly more events with triple antithrombotic therapy (OR, 2.12; 95% CI, 1.05-4.29; P = .04).

Conclusions: Based on our analysis, triple antithrombotic therapy is substantially more efficacious in reducing the occurrence of cardiovascular events and mortality in PCI-s patients with an indication for long-term OAC, compared with dual antiplatelet therapy. Although triple therapy predisposes patients to an increased risk of bleeding, especially major bleeding, it is the better choice for patients with a low bleeding risk.