Triple Antithrombotic Therapy versus Dual Antiplatelet Therapy Alone Following Anterior STEMI, a Systematic Review and Meta-Analysis With GRADE Assessment

Background Left ventricular thrombus (LVT) remains an important complication following anterior ST-elevation myocardial infarction (STEMI), despite widespread adoption of primary percutaneous coronary intervention (pPCl). Current guidelines supporting prophylactic oral anticoagulation in high-risk patients are based on limited evidence, and the balance between thromboembolic prevention and bleeding risk remains uncertain. PubMed, Embase and etc were searched for studies comparing triple antithrombotic therapy (TAPT; anticoagulation plus DAPT) versus DAPT alone in patients with anterior STEMI undergoing pPCI. Random-effects model was used to pool risk ratios with 95% confidence intervals (CI). Outcomes included mortality, bleeding, LVT, and etc. Main Text 7 studies including 3,692 participants were included. TAPT was associated with a significantly increased risk of bleeding compared with DAPT alone (RR: 2.10; 95% CI: 1.60-2.76; P<0.0001; I 2 =0%). No significant differences were observed in all-cause mortality (RR: 1.05; 95% CI: 0.54-2.04; P=0.89; I 2 =39%), recurrent myocardial infarction (RR: 1.52; 95% CI: 0.94-2.45; P=0.09; I 2 =0%), stroke (RR: 0.86; 95% CI: 0.20-3.73; P=0.84; I 2 =55%), LVT formation (RR: 0.54; 95% Cl: 0.21-1.40; P=0.21; l 2 =61%), NACE (RR: 0.93; 95% CI: 0.49-1.75; P=0.82; I 2 =77%), or embolic events (RR: 0.53; 95% CI: 0.21-1.33; P=0.18; I 2 =0%). Conclusions TAPT significantly increased bleeding risk compared with DAPT. No significant reductions were observed in ischemic outcomes; however, wide confidence intervals indicate limited precision and do not exclude a clinically meaningful benefit or harm. Current evidence therefore does not support routine prophylactic TAPT, and adequately powered contemporary randomised trials are needed.