Key result
DOAC DAT shows no safety or efficacy difference versus VKA TAT, with apixaban ranking best.
Why the study?
Creating an appropriate antithrombotic therapy for patients with AF who have undergone PCI remains a dilemma, with no head-to-head trials comparing DAT regimens to each other.
Does dual antithrombotic therapy improve safety and efficacy compared to triple antithrombotic therapy in patients with atrial fibrillation following a PCI?
Meta-Analysis (n=7,890)
Open-label
Randomized
Yes
Does dual antithrombotic therapy improve safety and efficacy compared to triple antithrombotic therapy in patients with atrial fibrillation following a PCI?
In patients with AF undergoing PCI, DAT regimens are as safe and effective as TAT, with specific DOACs offering varying probabilities of being the optimal choice for individual clinical endpoints.
Answers are grounded in this paper and cite their sources.
Supports DAT with DOACs as equivalent in safety and efficacy to TAT for AF post-PCI; extends NMA evidence for agent-specific rankings to guide selection.
Objective Creating an appropriate antithrombotic therapy for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) remains a dilemma. Several clinical trials compared the use of a dual antithrombotic therapy (DAT) regimen with a direct oral anticoagulants including (apixaban, dabigatran, edoxaban or rivaroxaban) and a P2Y 12 inhibitor versus a triple antithrombotic therapy (TAT) that includes a vitamin K antagonist plus aspirin and a P2Y 12 inhibitor in patients with AF who have undergone PCI. However, there are no head-to-head trials comparing the DAT regimens to each other. We aimed to compare the efficacy and safety of DAT regimens using a network meta-analysis (NMA) approach. Design A systematic review and NMA of randomised clinical trials. Methods We conducted a systematic literature review to identify relevant randomised clinical trials and performed a Bayesian NMA for International Society on Thrombosis and Haemostasis (ISTH) major or clinically relevant non-major (CRNM) bleeding, all-cause mortality, stroke, myocardial infarction (MI) and stent thrombosis outcomes. We used NetMetaXL V.1.6.1 and WinBUGS V.1.4.3 for the NMA and estimated the probability of ranking the treatments based on the surface under the cumulative ranking curve. Results The comparison between DAT regimens showed no significant difference in the safety or efficacy outcomes. Apixaban regimen was ranked first as the preferred therapy in terms of ISTH major or CRNM bleeding and stroke, with a probability of 52% and 54%, respectively. Rivaroxaban regimen was the preferred therapy in terms of MI and stent thrombosis, with a probability of 34% and 27%, respectively. Dabigatran regimen was ranked first in terms of all-cause mortality, with a probability of 28%. Conclusion The DAT regimens are as safe and effective as TAT regimens. However, ranking probabilities for the best option in the selected outcomes can be used to guide the selection among these agents based on different patients’ conditions.
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Altoukhi et al. (2020) conducted a meta-analysis in Atrial fibrillation following percutaneous coronary intervention or acute coronary syndrome (n=7,890). Dual antithrombotic therapy (DAT) with a direct oral anticoagulant and a P2Y12 inhibitor vs. Triple antithrombotic therapy (TAT) with a vitamin K antagonist, aspirin, and a P2Y12 inhibitor was evaluated on ISTH major or clinically relevant non-major (CRNM) bleeding, all-cause mortality, stroke, myocardial infarction, and stent thrombosis. Dual antithrombotic therapy regimens with direct oral anticoagulants showed no significant difference in safety or efficacy compared to triple antithrombotic therapy with vitamin K antagonists, with apixaban ranking as the preferred agent for reducing bleeding and stroke.
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