Key result
Dual therapy significantly reduced the risk of major bleeding compared to triple therapy (RR 0.63; 95% CI 0.50-0.80) without a statistically significant increase in major adverse cardiac events.
Why the study?
Does dual therapy with an oral anticoagulant and single antiplatelet agent reduce major bleeding compared to triple therapy in patients with an indication for anticoagulation after PCI or ACS?
Meta-Analysis
Does dual therapy with an oral anticoagulant and single antiplatelet agent reduce major bleeding compared to triple therapy in patients with an indication for anticoagulation after PCI or ACS?
Relative Risk: 0.63 (95% CI 0.5–0.8)
Dual antithrombotic therapy significantly reduces major bleeding compared to triple therapy without a significant increase in major adverse cardiac events in patients requiring anticoagulation after PCI or ACS.
May support dual over triple therapy to cut bleeding; leaves open confirmation in randomized trials.
BACKGROUND: For patients who have an indication for anticoagulation, it is controversial whether dual therapy with an oral anticoagulant and single antiplatelet agent can be used after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) instead of triple therapy with an oral anticoagulant and dual antiplatelet therapy. PARTICIPANTS AND METHODS: Twelve observational studies and four clinical trials were identified from three electronic databases from their inception to December, 2017. Pooled estimates were calculated using a random-effects model for meta-analysis. RESULTS: Compared with the triple therapy, dual therapy was associated with significantly lower risk of major bleeding [relative risk (RR), 0.63; 95% confidence interval (CI), 0.50-0.80] without statistically significant increase in major adverse cardiac events (RR, 1.04; 95% CI, 0.84-1.29), all-cause death (RR, 1.15; 95% CI, 0.77-1.71), cardiac death (RR, 1.04; 95% CI, 0.67-1.61), myocardial infarction (RR, 1.25; 95% CI, 0.98-1.59), stroke (RR, 1.27; 95% CI, 0.79-2.06), stent thrombosis (RR, 1.52; 95% CI, 0.96-2.41), and repeat revascularization (RR, 1.15; 95% CI, 0.87-1.52). Although risks of myocardial infarction and stent thrombosis were marginally higher in the dual therapy group, this trend was attenuated after excluding studies that exclusively included patients undergoing PCI for ACS, but not stable coronary artery disease. CONCLUSION: Dual therapy may be a reasonable alternative to triple therapy after PCI in patients with indication for chronic anticoagulation. However, further studies are needed to investigate efficacy of dual therapy, especially in the patients with higher ischemic risk, such as in ACS.
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Shin et al. (2018) conducted a meta-analysis in Indication for anticoagulation after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS). Dual therapy (oral anticoagulant and single antiplatelet agent) vs. Triple therapy (oral anticoagulant and dual antiplatelet therapy) was evaluated on Major bleeding (RR 0.63, 95% CI 0.50-0.80). Dual therapy significantly reduced the risk of major bleeding compared to triple therapy (RR 0.63; 95% CI 0.50-0.80) without a statistically significant increase in major adverse cardiac events.
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