Effect of triple versus dual antiplatelet therapy in patients undergoing percutaneous intervention: systematic review and meta-analysis with GRADE system

Introduction: To lower major adverse cardiac events following percutaneous coronary intervention (PCI), antiplatelet therapy should be continued. We evaluate triple antiplatelet therapy (TAT) versus standard dual treatment (DAT) in patients having percutaneous intervention for coronary artery disease. Methods: On 17 July 2023, we systematically searched PubMed, Scopus, and the Web of Science databases. This systematic review included studies that assess the effect of TAT versus DAT after PCI. The level of evidence of the included trials was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: 27 studies were included in this systematic review and meta-analysis. The meta-analysis showed that TAT is associated with a significant reduction in MACEs at nine and 12-month follow-up periods (RR = 0.39, 95% CI, 0.20-0.77; P = 0.006), (RR = 0.57, 95% CI, 0.45-0.71; P<0.00001), and target lesion revascularization (RR = 0.33, 95% CI, 0.15-0.73; P = 0.006), and (RR = 0.45, 95% CI, 0.28-0.73; P = 0.001), respectively. It also showed a significant reduction in target vessel revascularization during the nine-month follow-up period (RR = 0.62, 95% CI, 0.48-0.81; P = 0.0004). While dual therapy has an insignificant reduction in any-degree bleeding at six and 12-month follow-up periods (RR = 1.02, 95% CI, 0.54-1.94; P = 0.94), (RR = 1.28, 95% CI, 0.92-1.77; P = 0.14), compared with triple therapy. The level of evidence for MACEs, TLR, and any degree of bleeding is moderate, but it is low for TVR, any cause of death, cardiac death, and stent thrombosis. All of them are assessed with a 12-month follow-up duration. Conclusion: TAT appears to be more effective than DAT in reducing MACEs, TLR, and TVR in ACS patients after PCI. TAT is almost as safe as DAT in these patients because there is a statistically insignificant difference in most of the adverse effects between these two groups.