Adding a novel oral anticoagulant to dual antiplatelet therapy after an acute coronary syndrome modestly reduced MACE (HR 0.87; 95% CI 0.80-0.95) but more than doubled bleeding (HR 2.34; 95% CI 2.06-2.66).
Meta-Analysis (n=30,866)
Does the addition of a novel oral anticoagulant to single or dual antiplatelet therapy reduce major adverse cardiovascular events in patients with a recent acute coronary syndrome?
In patients with recent ACS, adding a novel oral anticoagulant to antiplatelet therapy yields a modest reduction in ischemic events at the cost of a substantial increase in bleeding.
Hazard Ratio: 0.87 (95% CI 0.8–0.95)
BACKGROUND: Oral anticoagulation in addition to antiplatelet treatment after an acute coronary syndrome might reduce ischaemic events but increase bleeding risk. We performed a meta-analysis to evaluate the efficacy and safety of adding direct thrombin or factor-Xa inhibition by any of the novel oral anticoagulants (apixaban, dabigatran, darexaban, rivaroxaban, and ximelagatran) to single (aspirin) or dual (aspirin and clopidogrel) antiplatelet therapy in this setting. METHODS AND RESULTS: All seven published randomized, placebo-controlled phase II and III studies of novel oral anticoagulants in acute coronary syndromes were included. The database consisted of 30 866 patients, 4135 (13.4%) on single, and 26 731 (86.6%) on dual antiplatelet therapy, with a non-ST- or ST-elevation acute coronary syndrome within the last 7-14 days. We defined major adverse cardiovascular events (MACEs) as the composite of all-cause mortality, myocardial infarction, or stroke; and clinically significant bleeding as the composite of major and non-major bleeding requiring medical attention according to the study definitions. When compared with aspirin alone the combination of an oral anticoagulant and aspirin reduced the incidence of MACE hazard ratio (HR) and 95% confidence interval 0.70; 0.59-0.84, but increased clinically significant bleeding (HR: 1.79; 1.54-2.09). Compared with dual antiplatelet therapy with aspirin and clopidogrel, adding an oral anticoagulant decreased the incidence of MACE modestly (HR: 0.87; 0.80-0.95), but more than doubled the bleeding (HR: 2.34; 2.06-2.66). Heterogeneity between studies was low, and results were similar when restricting the analysis to phase III studies. CONCLUSION: In patients with a recent acute coronary syndrome, the addition of a new oral anticoagulant to antiplatelet therapy results in a modest reduction in cardiovascular events but a substantial increase in bleeding, most pronounced when new oral anticoagulants are combined with dual antiplatelet therapy.
Oldgren et al. (Wed,) conducted a meta-analysis in acute coronary syndrome (n=30,866). novel oral anticoagulants vs. single or dual antiplatelet therapy was evaluated on major adverse cardiovascular events (MACEs) (composite of all-cause mortality, myocardial infarction, or stroke) (HR 0.87, 95% CI 0.80-0.95). Adding a novel oral anticoagulant to dual antiplatelet therapy after an acute coronary syndrome modestly reduced MACE (HR 0.87; 95% CI 0.80-0.95) but more than doubled bleeding (HR 2.34; 95% CI 2.06-2.66).