May 16, 2019International Heart JournalOpen Access

Clinical Outcomes of Antithrombotic Strategies for Patients with Atrial Fibrillation After Percutaneous Coronary Intervention

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Atrial fibrillation after percutaneous coronary intervention (n=16382). Intervention: Non-vitamin K oral anticoagulants (NOAC) plus P2Y12 inhibitor vs. Vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT). Primary outcome: Major bleeding (OR 0.57, 95% CI 0.43-0.75).

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Key result

Non-vitamin K oral anticoagulants plus a P2Y12 inhibitor significantly reduced the risk of major bleeding compared with vitamin K antagonist plus dual antiplatelet therapy (OR 0.57).

Why the study?

Antithrombotic strategies for patients with atrial fibrillation undergoing PCI remain challenging, prompting an evaluation of the best strategy via network meta-analysis.

Does NOAC plus P2Y12 inhibitor or VKA plus single antiplatelet therapy reduce major bleeding compared to VKA plus dual antiplatelet therapy in patients with atrial fibrillation undergoing PCI?

Study Design

Type

Meta-Analysis (n=16,382)

Structured PICO

Does NOAC plus P2Y12 inhibitor or VKA plus single antiplatelet therapy reduce major bleeding compared to VKA plus dual antiplatelet therapy in patients with atrial fibrillation undergoing PCI?

Population

16,382 patients with atrial fibrillation undergoing percutaneous coronary intervention, followed for 3 to 12 months across 15 studies.

Intervention

Non-vitamin K oral anticoagulants (NOAC) plus P2Y12 inhibitor, or Vitamin K antagonist (VKA) plus single antiplatelet therapy (clopidogrel or aspirin).

Comparator

VKA-based triple therapy (VKA plus dual antiplatelet therapy [DAPT]).

Outcome

Major bleeding.safety

Main Result

Odds Ratio: 0.57 (95% CI 0.43–0.75)

In AF patients undergoing PCI, NOAC plus a P2Y12 inhibitor or VKA plus clopidogrel reduces major bleeding compared to VKA-based triple therapy without increasing thrombotic events, whereas VKA plus aspirin increases ischemic stroke and mortality compared to VKA plus clopidogrel.

Limitations

Not a patient-level meta-analysis, which prevents additional subgroup analyses.
The duration of VKA-based triple therapy and the baseline patient characteristics were slightly different across the included studies.
Minimal bias can occur due to the exclusion of the DAPT regimen for AF patients after PCI.
Findings were derived from a network meta-analysis with direct or indirect comparisons and not large-scale head-to-head RCTs.
Duration of VKA-based triple therapy and baseline patient characteristics were slightly different across the included studies.
Findings derived from network meta-analysis based on direct or indirect comparisons and not large-scale head-to-head RCTs.

Implication

Supports preferring NOAC plus P2Y12 inhibitor to reduce major bleeding; confirms and extends randomized evidence for safer antithrombotic regimens.

Abstract

Antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) remain challenging. This study aims to explore the best antithrombotic strategy for AF patients after PCI based on a network meta-analysis. This study was registered in PROSPERO (CRD42018093928). The PubMed, Cochrane, and EMBASE databases were searched to identify clinical trials concerning antithrombotic therapy for AF patients with PCI from inception to April 2018. Pairwise and network meta-analysis were conducted to compare clinical outcomes of different antithrombotic therapy. The primary endpoint was major bleeding. Fifteen studies including 16,382 patients were identified with follow-up ranging from 3 to 12 months. Non-vitamin K oral anticoagulants (NOAC) plus P2Y12 inhibitor ranked first with a reduced risk of major bleeding compared with vitamin K antagonist (VKA) plus dual antiplatelet therapy (OR: 0.57, 95% CI: 0.43-0.75) but with no significant difference compared with VKA plus single platelet therapy (OR: 0.85, 95% CI: 0.62-1.16). Similar thrombotic events were evident among these groups. Subgroup analysis showed that VKA plus aspirin exhibited a similar risk of major bleeding compared with VKA plus clopidogrel (OR: 0.94, 95% CI: 0.73-1.23) but was associated with increased risks of ischaemic stroke (OR: 2.10, 95% CI: 1.33-3.32) and all-cause death (OR: 1.77, 95% CI: 1.15-2.74) versus VKA plus clopidogrel. In AF patients undergoing PCI, NOAC plus P2Y12 inhibitor and VKA plus clopidogrel, but not VKA plus aspirin, were associated with reduced risk of major bleeding compared with the recommended VKA-based triple therapy, while thrombotic events were similar among these treatments.

Discussion

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Cite This Study

Gao et al. (2019) conducted a meta-analysis in Atrial fibrillation after percutaneous coronary intervention (n=16,382). Non-vitamin K oral anticoagulants (NOAC) plus P2Y12 inhibitor vs. Vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT) was evaluated on Major bleeding (OR 0.57, 95% CI 0.43-0.75). Non-vitamin K oral anticoagulants plus a P2Y12 inhibitor significantly reduced the risk of major bleeding compared with vitamin K antagonist plus dual antiplatelet therapy (OR 0.57).

synapsesocial.com/papers/6a915377d73fb5289dab523b https://doi.org/10.1536/ihj.18-464