Key result
Triple therapy with DAPT and a vitamin K antagonist was associated with a significantly higher risk of major bleeding but lower risks of stroke, stent thrombosis, and all-cause mortality compared to DAPT alone in patients with atrial fibrillation after coronary stenting.
Why the study?
Does the addition of a vitamin K antagonist to dual antiplatelet therapy improve clinical outcomes and increase bleeding in patients with atrial fibrillation after coronary stent implantation?
Meta-Analysis (n=20,456)
Does the addition of a vitamin K antagonist to dual antiplatelet therapy improve clinical outcomes and increase bleeding in patients with atrial fibrillation after coronary stent implantation?
Odds Ratio: 0.62 (95% CI 0.5–0.77)
p-value: p=<0.0001
In patients with atrial fibrillation undergoing PCI, adding a vitamin K antagonist to DAPT significantly reduces stroke, stent thrombosis, and all-cause mortality, but at the cost of a significantly increased risk of major bleeding.
Supports individualized regimens balancing bleeding versus ischemic risks in AF post-stenting; reinforces meta-analytic evidence for VKA addition.
BACKGROUND: Data regarding the clinical outcomes in patients with atrial fibrillation (AF) receiving dual antiplatelet therapy (DAPT) and an anticoagulant in addition to DAPT (DAPT + vitamin K antagonist [VKA]) after coronary stent implantation are still controversial. Therefore, in order to solve this issue, we aim to compare the adverse clinical outcomes in AF patients receiving DAPT and DAPT + VKA after percutaneous coronary intervention and stenting (PCI-S). METHODS: Observational studies comparing the adverse clinical outcomes such as major bleeding, major adverse cardiovascular events, stroke, myocardial infarction, all-cause mortality, and stent thrombosis (ST) in AF patients receiving DAPT + VKA therapy, and DAPT after PCI-S have been searched from Medline, EMBASE, and PubMed databases. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to express the pooled effect on discontinuous variables, and the pooled analyses were performed with RevMan 5.3. RESULTS: Eighteen studies consisting of a total of 20,456 patients with AF (7203 patients received DAPT + VKA and 13,253 patients received DAPT after PCI-S) were included in this meta-analysis. At a mean follow-up period of 15 months, the risk of major bleeding was significantly higher in DAPT + VKA group, with OR 0.62 (95% CI 0.50-0.77, P < 0.0001). There was no significant differences in myocardial infarction and major adverse cardiovascular event between DAPT + VKA and DAPT, with OR 1.27 (95% CI 0.92-1.77, P = 0.15) and OR 1.17 (95% CI 0.99-1.39, P = 0.07), respectively. However, the ST, stroke, and all-cause mortality were significantly lower in the DAPT + VKA group, with OR 1.98 (95% CI 1.03-3.81, P = 0.04), 1.59 (95% CI 1.08-2.34, P = 0.02), and 1.41 (95% CI 1.03-1.94, P = 0.03), respectively. CONCLUSION: At a mean follow-up period of 15 months, DAPT + VKA was associated with significantly lower risk of stroke, ST, and all-cause mortality in AF patients after PCI-S compared with DAPT group. However, the risk of major bleeding was significantly higher in the DAPT + VKA group.
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Chaudhary et al. (2016) conducted a meta-analysis in Atrial fibrillation and coronary artery disease after percutaneous coronary intervention and stenting (n=20,456). DAPT + VKA (Triple Therapy) vs. DAPT (Dual antiplatelet therapy) was evaluated on Major bleeding (OR 0.62, 95% CI 0.50-0.77, p=<0.0001). Triple therapy with DAPT and a vitamin K antagonist was associated with a significantly higher risk of major bleeding but lower risks of stroke, stent thrombosis, and all-cause mortality compared to DAPT alone in patients with atrial fibrillation after coronary stenting.
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