September 10, 2015
View Full PaperEvaluation of the efficacy and safety of dual antiplatelet therapy with or without warfarin in patients with a clinical indication for DAPT and chronic anticoagulation: A meta‐analysis of observational studies
Key Result
Triple therapy compared to DAPT showed no significant difference in all-cause mortality (RR 0.81; 95% CI 0.61-1.08; P=0.15), but increased major bleeding and reduced ischemic stroke.
Study Design
Type
Meta-Analysis (n=14,921)
Structured PICO
Does triple therapy (DAPT plus warfarin) improve outcomes compared to DAPT alone in patients post MI or PCI-S requiring chronic oral anticoagulation?
P
Population
14,921 patients from 17 observational studies post myocardial infarction (MI) or percutaneous coronary intervention with stenting (PCI-S) who also require chronic oral anticoagulation (majority for atrial fibrillation).
I
Intervention
Triple therapy (dual antiplatelet therapy plus warfarin)
C
Comparator
Dual antiplatelet therapy (DAPT) alone
O
Outcome
All-cause mortalityhard clinical
In patients post-MI or PCI requiring chronic anticoagulation, triple therapy increases major bleeding and reduces ischemic stroke compared to DAPT alone, with no significant difference in all-cause mortality.
Main Result
Effect estimate: RR 0.81 (95% CI 0.61-1.08)
p-value: p=0.15
Abstract
OBJECTIVE: To compare the efficacy and safety of dual antiplatelet therapy (DAPT) and triple therapy (TT, dual antiplatelet plus warfarin) in patients with myocardial infarction (MI) or PCI with stenting (PCI-S) who also require chronic oral anticoagulation. BACKGROUND: Recommendations for the optimal antiplatelet/anticoagulant treatment regimen for patients undergoing PCI-S or MI who also require oral anticoagulation are largely based on evidence from observational studies and expert opinions. METHODS: A systematic search was performed for studies comparing TT vs. DAPT in patients post PCI-S or MI and requiring chronic anticoagulation. Primary outcome was all-cause mortality. Secondary outcomes were ischemic stroke, major bleeding, MI, and stent thrombosis. Pooled relative risks (RR) were calculated using random effects model. RESULTS: A total of 17 studies were included, with 14,921 patients TT: 5,819(39%) and DAPT: 9,102(61%) and a mean follow-up of 1.6 years. The majority of patients required oral anticoagulation for atrial fibrillation. Compared to DAPT, patients treated with TT had no significant difference in all-cause mortality RR: 0.81, 95% confidence interval (CI): 0.61-1.08, P = 0.15, MI RR 0.74, 95% CI: 0.51-1.06, P = 0.10, and stent thrombosis RR 0.67, 95% CI: 0.35-1.30, P = 0.24. Patients treated with TT had significantly increased risk of major bleeding RR 1.20, 95% CI: 1.03-1.39, P = 0.02, whereas the risk for ischemic stroke was significantly lower RR 0.59, 95% CI: 0.38-0.92, P = 0.02. CONCLUSIONS: All-cause mortality appears similar in patients treated with TT or DAPT although TT was associated with higher rates of major bleeding and a lower risk for ischemic stroke. © 2015 Wiley Periodicals, Inc.