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. 2020 Apr 8;9(4):1062.
doi: 10.3390/jcm9041062.

Antithrombotic Strategies in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention: A Systemic Review and Network Meta-Analysis of Randomized Controlled Trials

Su-Kiat Chua  1   2   3 , Lung-Ching Chen  2   3 , Kou-Gi Shyu  2   3 , Jun-Jack Cheng  2   3 , Huei-Fong Hung  2   3 , Chiung-Zuan Chiu  2   3 , Chiu-Mei Lin  1   4
Affiliations

Antithrombotic Strategies in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention: A Systemic Review and Network Meta-Analysis of Randomized Controlled Trials

Su-Kiat Chua et al. J Clin Med. .

Abstract

Up to 10% of patients with atrial fibrillation (AF) undergo percutaneous coronary intervention (PCI). A systematic review and network meta-analysis were conducted by searching PubMed, Embase, and the Cochrane database of systematic reviews for randomized control trials that studied the safety and efficacy of different antithrombotic strategies in these patients. Six studies, including 12,158 patients were included. Compared to that in the triple antithrombotic therapy group (vitamin K antagonist (VKA) plus P2Y12 inhibitor and aspirin), thrombolysis in myocardial infarction (TIMI) major bleeding was significantly reduced in the dual antithrombotic therapy (non-vitamin K oral anticoagulants (NOACs) plus P2Y12 inhibitor) group by 47% (Odds ratio (OR), 0.53; 95% credible interval [CrI], 0.35-0.78; I2 = 0%). Besides, NOAC plus a P2Y12 inhibitor was associated with less intracranial hemorrhage compared to VKA plus single antiplatelet therapy (OR: 0.20, 95% CrI: 0.05-0.77). There was no significant difference in the trial-defined major adverse cardiac events or the individual outcomes of all-cause mortality, cardiovascular death, myocardial infarction, stroke or stent thrombosis among all antithrombotic strategies. In conclusion, antithrombotic strategy of NOACs plus P2Y12 inhibitor is safer than, and as effective as, the strategies including aspirin when used in AF patients undergoing PCI.

Keywords: Atrial fibrillation; antithrombotic therapy; dual anti-thrombotic therapy; percutaneous coronary intervention; triple antithrombotic therapy.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow diagram of included studies.
Figure 2
Figure 2
Network of four antithrombotic therapy strategies. The nodes represent the antithrombotic therapy strategies to be compared; the size of nodes is proportional to the number of patients included for the different antithrombotic therapy strategies. The edges represent the direct comparisons between the antithrombotic therapy strategies and the thickness is proportional to the sample size of the studies.
Figure 3
Figure 3
Forest plots for safety outcomes. Odds ratio and 95% credible intervals (CrI) compared with vitamin antagonist (VKA) plus dual antiplatelet therapy (DAPT) are plotted. The estimated between-trial effect heterogeneity and its 95% CrI (in standard deviation of the log odds ratio scale) from network meta-analysis for each outcome is (A) TIMI major bleeding, 0.22 (95% CrI, 0.10–0.55), I2 = 0%; (B) TIMI major and minor bleeding, 0.46 (95% CrI, 0.09–0.84), I2 = 60%; (C) Trial-defined primary safety outcome, 0.48 (95% CrI, 0.08–1.08), I2 = 70%; (D) Intracranial hemorrhage, 0.41 (95% CrI, 0.26–1.08), I2 = 0%. DAPT, dual antiplatelet therapy; NOAC, non-vitamin K antagonist oral anticoagulant; SAPT, single antiplatelet therapy; VKA, vitamin K antagonist.
Figure 4
Figure 4
Forest plots for efficacy outcomes. Odds ratio and 95% credible intervals (CrI) compared with vitamin antagonist (VKA) plus dual antiplatelet therapy (DAPT) are plotted. The estimated between-trial effect heterogeneity and its 95% CrI (in standard deviation of the log odds ratio scale) from network meta-analysis for each outcome is (A) Trial-defined primary MACEs, 0.23 (95% CrI, 0.09–0.55), I2 = 7%; (B) All-cause death, 0.24 (95% CrI, 0.13–0.60), I2 = 0%; (C) Cardiovascular death, 0.17 (95% CrI, 0.12–0.46), I2 = 0%; (D) Myocardial infarction, 0.15 (95% CrI, 0.05–0.35), I2 = 0%. (E) Stroke, 0.41 (95% CrI, 0.06–0.90), I2 = 0%; (F) Stent thrombosis, 0.30 (95% CrI, 0.09–0.69), I2 = 0%. MACEs: major adverse cardiovascular events; DAPT: dual antiplatelet therapy; NOAC: non-vitamin K antagonist oral anticoagulant; SAPT: single antiplatelet therapy; VKA: vitamin K antagonist.
Figure 5
Figure 5
Odds ratio (OR) for TIMI major bleeding and the trial defined major adverse cardiovascular events (MACE).
See this image and copyright information in PMC

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