Double or triple antithrombotic therapy after coronary stenting and atrial fibrillation: A systematic review and meta-analysis of randomized clinical trials

• Published in: International journal of cardiology Vol. 302; pp. 95 - 102
• Main Authors: Andò, Giuseppe, Costa, Francesco
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 01.03.2020
• Subjects: Atrial fibrillation; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Double antithrombotic therapy (DAT); Drug Therapy, Combination; Fibrinolytic Agents - therapeutic use; Humans; Non-vitamin K oral anticoagulant (NOAC); Percutaneous coronary intervention (PCI); Percutaneous Coronary Intervention - methods; Platelet Aggregation Inhibitors - therapeutic use; Randomized Controlled Trials as Topic; Stent thrombosis; Stents; Thrombosis - etiology; Thrombosis - prevention & control; Triple antithrombotic therapy (TAT); Percutaneous coronary intervention (PCI); Non-vitamin K oral anticoagulant (NOAC); Triple antithrombotic therapy (TAT); Stent thrombosis; Double antithrombotic therapy (DAT); Atrial fibrillation
• ISSN: 0167-5273; 1874-1754
• DOI: 10.1016/j.ijcard.2019.12.054

Double or triple antithrombotic therapy (DAT/TAT) including or excluding aspirin in association with oral anticoagulant and P2Y12 inhibitor are currently two available options in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). We evaluated efficacy and safety outcomes for DAT vs. TAT. Four non-vitamin K oral anticoagulants (NOAC)-based randomized controlled trials comparing DAT vs. TAT with a total of 10,938 patients were pooled. Bleeding events occurred more frequently than ischemic events. DAT as compared to TAT was associated to an increased risk of stent thrombosis (RR 1.54, 95% CI 1.10–2.14; p = 0.03), myocardial infarction (RR 1.23, 95% CI 1.04–1.46; p = 0.03) and cardiovascular mortality (RR 1.09, 95% CI 1.01–1.19; p = 0.04) and to a reduced risk of ISTH major or clinically relevant non-major bleeding (RR 0.59, 95% CI 0.62–0.93; p = 0.03). A consistent effect was observed in all safety endpoints. Intracranial haemorrhage was numerically reduced by DAT. No difference for all-cause death was observed. Antithrombotic treatment in patients with AF undergoing PCI represents a trade-off between ischemia and bleeding. A careful patient selection based on baseline ischemic and bleeding risk may optimize the net clinical balance in this population. •In AF patients undergoing PCI or with ACS, withdrawal of aspirin, transitioning from a TAT to a DAT, reduces bleeding events.•A concomitant, yet less frequent, increased risk of ST and MI with DAT is observed.•DAT after an initial brief treatment with corresponding TAT appears the best strategy for the majority of patients.•Selected patients deemed at elevated ischemic risk might still benefit from a longer course of TAT.•A personalized treatment strategy based on individual ischemic and bleeding risk is essential to optimize patients' net outcome.