Key result
Dual therapy with either a vitamin K antagonist or a direct oral anticoagulant plus an antiplatelet significantly reduced the risk of major bleeding compared to triple therapy.
Why the study?
Patients undergoing PCI requiring anticoagulant therapy face increased bleeding risk, and the optimal antithrombotic regimen remains uncertain.
Does dual therapy (anticoagulant plus single antiplatelet) reduce major bleeding compared to classic triple therapy in patients undergoing PCI who require anticoagulation?
Meta-Analysis (n=22,179)
Does dual therapy (anticoagulant plus single antiplatelet) reduce major bleeding compared to classic triple therapy in patients undergoing PCI who require anticoagulation?
Relative Risk: 0.51 (95% CI 0.3–0.87)
p-value: p=0.014
In anticoagulated patients undergoing PCI, dual therapy with an anticoagulant and a single antiplatelet significantly reduces major bleeding and all-cause mortality compared to classic triple therapy.
Supports dual over triple antithrombotic therapy to lower bleeding in practice; confirms and extends Level 1 meta-analytic evidence.
Background Patients undergoing percutaneous coronary intervention (PCI) who require anticoagulant therapy are at increased risk of bleeding. The optimal regimen for these patients is uncertain. This study aimed to compare safety and efficacy of antithrombotic regimens used in patients undergoing PCI with concomitant anticoagulant therapy. Methods A systematic review and network meta-analysis was performed among studies comparing antithrombotic regimens for anticoagulated patients undergoing PCI. The primary outcome of interest was major bleeding. The secondary outcomes were coronary events. The reference intervention was classic triple therapy (aspirin plus clopidogrel plus vitamin K antagonist). Cluster rank incorporating risk (major bleeding) and benefit (all-cause death) was performed to identify the most appropriate regimen(s). Results There were 3 RCTs (6 interventions) and 29 non-RCTs (8 interventions) that met the inclusion criteria with 22,179 patients. Network meta-analysis of RCTs indicated that dual therapy (DT), either with vitamin K antagonist (VKA) or direct anticoagulant (DOAC) plus an antiplatelet, significantly reduced the risk of major bleeding compared to triple therapy (TT) [pooled RR of 0.51 (0.30-0.87) and 0.68 (0.49-0.94), respectively]. In addition, VKA-DT significantly reduced the risk of all-cause death compared to TT [pooled RR of 0.40 (0.17-0.93)]. Results from network meta-analysis of non-RCT paralleled that of RCTs. No significant differences of coronary events were found. Conclusions In conclusion, for anticoagulated patients undergoing PCI, dual therapy, either with warfarin or DOAC plus an antiplatelet, should be considered due to its optimal balance on efficacy and safety.
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Bunmark et al. (2018) conducted a meta-analysis in Patients undergoing percutaneous coronary intervention (PCI) who require anticoagulant therapy (n=22,179). Dual therapy (VKA or DOAC plus an antiplatelet) vs. Triple therapy (aspirin plus clopidogrel plus VKA) was evaluated on Major bleeding (RR 0.51, 95% CI 0.30-0.87, p=0.014). Dual therapy with either a vitamin K antagonist or a direct oral anticoagulant plus an antiplatelet significantly reduced the risk of major bleeding compared to triple therapy.
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