Efficacy and safety of triple versus dual antithrombotic therapy in atrial fibrillation and ischemic heart disease: a systematic review and meta-analysis

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.

Keywords: atrial fibrillation; dual therapy; ischemic heart disease; triple therapy.

Figure 1. Flow chart of the study selection process for this meta-analysis

Abbreviations: IHD = ischemic heart disease; AF = atrial fibrillation; TT = triple therapy (an oral anticoagulant plus 2 antiplatelet drugs); DAPT = dual therapy (2 antiplatelet drugs); DT = dual therapy (an oral anticoagulant plus one antiplatelet drug).

Figure 2. Forest plot for the comparative analysis of the efficacies of TT and DAPT in patients with AF and IHD

Abbreviations: IHD = ischemic heart disease; AF = atrial fibrillation; TT = triple therapy (an oral anticoagulant plus 2 antiplatelet drugs); DAPT = dual therapy (2 antiplatelet drugs); MI = myocardial infarction; ACS = acute coronary syndrome; TE = thromboembolism; MACCEs = major adverse cardiac and cerebrovascular events; SE = standard error; CI = confidence interval; IV = inverse of the variance.

Figure 3. Forest plot for the comparative analysis of the efficacies of TT and DT in patients with AF and IHD

Abbreviations: IHD = ischemic heart disease; AF = atrial fibrillation; TT = triple therapy (an oral anticoagulant plus 2 antiplatelet drugs); DT = dual therapy (an oral anticoagulant plus one antiplatelet drug); MI = myocardial infarction; ACS = acute coronary syndrome; TE = thromboembolism; MACCEs = major adverse cardiac and cerebrovascular events; SE = standard error; CI = confidence interval; IV = inverse of the variance.

Figure 4. Forest plot for the comparative analysis of the safeties of TT and DAPT in patients with AF and IHD

Abbreviations: IHD = ischemic heart disease; AF = atrial fibrillation; TT = triple therapy (an oral anticoagulant plus 2 antiplatelet drugs); DAPT = dual therapy (2 antiplatelet drugs); MI = myocardial infarction; MACCEs = major adverse cardiac and cerebrovascular events; SE = standard error; CI = confidence interval; IV = inverse of the variance.

Figure 5. Forest plot for the comparative analysis of the safeties of TT and DT in patients with AF and IHD

Abbreviations: IHD = ischemic heart disease; AF = atrial fibrillation; TT = triple therapy (an oral anticoagulant plus 2 antiplatelet drugs); DT = dual therapy (an oral anticoagulant plus one antiplatelet drug); MI = myocardial infarction; MACCEs = major adverse cardiac and cerebrovascular events; SE = standard error; CI = confidence interval; IV = inverse of the variance.