Triple antithrombotic therapy in patients with atrial fibrillation who have undergone percutaneous coronary intervention with stent implantation

Arden R. Barry; Margaret L. Ackman

doi:10.2146/ajhp110556

August 16, 2012American Journal of Health-System Pharmacy

Triple antithrombotic therapy in patients with atrial fibrillation who have undergone percutaneous coronary intervention with stent implantation

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Why the study?

Does triple antithrombotic therapy reduce major adverse cardiac events and all-cause mortality compared to dual antiplatelet therapy in patients with atrial fibrillation who have undergone percutaneous coronary intervention with stent implantation?

Structured PICO

Does triple antithrombotic therapy reduce major adverse cardiac events and all-cause mortality compared to dual antiplatelet therapy in patients with atrial fibrillation who have undergone percutaneous coronary intervention with stent implantation?

P

Population

Patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) with stent implantation (based on 10 cohort studies and 1 meta-analysis)

I

Intervention

Triple antithrombotic therapy

C

Comparator

Dual antiplatelet therapy

O

Outcome

Major adverse cardiac events, all-cause mortality, and major bleedingcomposite

In patients with atrial fibrillation undergoing PCI, triple antithrombotic therapy reduces major adverse cardiac events and mortality compared to dual antiplatelet therapy, but significantly increases the risk of major bleeding.

Limitations

Heterogeneous methodology of available studies
Heterogeneous definitions for bleeding
Reliance on nonrandomized and small cohort studies

Implication

Triple therapy cuts ischemic events and mortality in AF-PCI patients but doubles major bleeding; extends meta-analytic support while cautioning against routine use.

Abstract

PURPOSE: The efficacy and safety of triple antithrombotic therapy in patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) with stent implantation are reviewed. SUMMARY: A systematic literature search of PubMed, EMBASE, and International Pharmaceutical Abstracts identified a total of 10 cohort studies and one meta-analysis investigating triple antithrombotic therapy in this patient population. With respect to efficacy, evidence from nonrandomized studies supports the superiority of triple antithrombotic therapy over dual antiplatelet therapy at preventing major adverse cardiac events and all-cause mortality. With respect to safety, the heterogeneous methodology and definitions for bleeding in the studies do not allow for easy interpretation and quantification of bleeding risk. There appears to be qualitative consistency that the rate of bleeding is higher with triple antithrombotic therapy compared with dual antiplatelet therapy. The meta-analysis, as well as a recent large registry data cohort study, demonstrated a twofold increase in the risk of major bleeding with triple antithrombotic therapy. CONCLUSION: The heterogeneous methodology of the available studies does not allow for conclusive interpretation and quantification of the efficacy and safety of triple antithrombotic therapy in patients with AF undergoing PCI with stent implantation compared with dual antiplatelet therapy. Evidence from small cohort studies support the benefit of triple antithrombotic therapy at reducing major adverse cardiac events and all-cause mortality with higher rates of bleeding.