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Review
. 2019 Sep;42(9):839-846.
doi: 10.1002/clc.23224. Epub 2019 Jul 9.

Vitamin K antagonist vs direct oral anticoagulants with antiplatelet therapy in dual or triple therapy after percutaneous coronary intervention or acute coronary syndrome in atrial fibrillation: Meta-analysis of randomized controlled trials

Vincent Roule  1   2 , Pierre Ardouin  1 , Clément Briet  1 , Adrien Lemaitre  1 , Mathieu Bignon  1 , Rémi Sabatier  1 , Laure Champ-Rigot  1   2 , Paul Milliez  1 , Katrien Blanchart  1 , Farzin Beygui  1   2   3
Affiliations
Review

Vitamin K antagonist vs direct oral anticoagulants with antiplatelet therapy in dual or triple therapy after percutaneous coronary intervention or acute coronary syndrome in atrial fibrillation: Meta-analysis of randomized controlled trials

Vincent Roule et al. Clin Cardiol. 2019 Sep.

Abstract

Background: The combination of vitamin K antagonists (VKA) for atrial fibrillation (AF) and antiplatelet agents following percutaneous coronary intervention (PCI) is associated with an increased bleeding risk.

Hypothesis: Direct oral anticoagulants (DOAC) are associated with a greater safety profile but the optimal antithrombotic treatment strategy, especially when considering ischemic events, is unclear.

Methods: We performed a meta-analysis of randomized controlled trials comparing outcomes in AF patients following PCI and/or acute coronary syndrome (ACS) when treated with DOAC vs VKA, both in combination with one (dual) or two (triple) antiplatelet regimens. A systematic review was performed by searches of electronic databases MEDLINE (source PubMed) and the Cochrane Controlled Clinical Trials Register Database as well as Cardiology annual meetings. Three studies were finally included.

Results: Compared to VKA triple therapy, the use of DOAC was associated with a decreased risk of any bleeding (relative risk [RR] 0.68 [0.62; 0.74]), major bleeding (RR 0.61 [0.51; 0.75]) and intracranial bleeding (RR 0.33 [0.17; 0.66]) and similar rates of the composite efficacy endpoint (RR 1.0 [0.87; 1.14]) and its components. Similar and consistent results were observed with both dual and triple therapy including a DOAC compared to VKA.

Conclusion: Our meta-analysis supports the use of dual therapy combining a DOAC and clopidogrel as the default regimen in most AF patients after PCI and/or ACS.

Keywords: atrial fibrillation; direct oral anticoagulant; dual therapy; percutaneous coronary intervention; triple therapy.

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Conflict of interest statement

The authors declare no potential conflict of interests.

Figures

Figure 1
Figure 1
Flow diagram of meta‐analysis trial selection. DOAC, direct oral anticoagulants; PCI, percutaneous coronary intervention; RCT, randomized controlled trials
Figure 2
Figure 2
Forest plots of selected studies comparing the effect of direct oral anticoagulants (DOAC) vs vitamin K antagonists (VKA) on any significant bleeding (A), major bleeding (B), intracranial bleeding (C), the composite efficacy endpoint of the studies (D), all‐causes death (E), cardiovascular death (F), stroke (G), myocardial infarction (H) and stent thrombosis (I). RR, risk ratio
See this image and copyright information in PMC

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