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Hayek A, MacDonald BJ, Marquis-Gravel G, Bainey KR, Mansour S, Ackman ML, Cantor WJ, Turgeon RD. Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease With Recent or Remote Events: Systematic Review and Meta-analysis. CJC Open 2024; 6:708-720. [PMID: 38846448 PMCID: PMC11150964 DOI: 10.1016/j.cjco.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/06/2024] [Indexed: 06/09/2024] Open
Abstract
Background Ongoing debate remains regarding optimal antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease. Methods We performed a systematic review and meta-analysis to synthesize randomized controlled trials (RCTs) comparing the following: (i) dual-pathway therapy (DPT; oral anticoagulant [OAC] plus antiplatelet) vs triple therapy (OAC and dual-antiplatelet therapy) after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS), and (iii) OAC monotherapy vs DPT at least 1 year after PCI or ACS. Following a 2-stage process, we identified systematic reviews published between 2019 and 2022 on these 2 clinical questions, and we updated the most comprehensive search for additional RCTs published up to October 2022. Outcomes of interest were major adverse cardiovascular events (MACE), death, stent thrombosis, and major bleeding. We estimated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model. Results Based on 6 RCTs (n = 10,435), DPT reduced major bleeding (RR 0.62, 95% CI 0.52-0.73) and increased stent thrombosis (RR 1.55, 95% CI 1.02-2.36), vs triple therapy after PCI or medically-managed ACS, with no significant differences in MACE and death. In 2 RCTs (n = 2905), OAC monotherapy reduced major bleeding (RR 0.66, 95% CI 0.49-0.91) vs DPT in AF patients with remote PCI or ACS, with no significant differences in MACE or death. Conclusions In patients with AF and coronary artery disease, using less-aggressive antithrombotic treatment (DPT after PCI or ACS, and OAC alone after remote PCI or ACS) reduced major bleeding, with an increase in stent thrombosis with recent PCI. These results support a minimalist yet personalized antithrombotic strategy for these patients.
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Affiliation(s)
- Ahmad Hayek
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Blair J. MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Margaret L. Ackman
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Warren J. Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Yi YH, Gong S, Gong TL, Zhou LY, Hu C, Xu WH. New Oral Anticoagulants for Venous Thromboembolism Prophylaxis in Total Hip and Knee Arthroplasty: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2022; 12:775126. [PMID: 35111051 PMCID: PMC8801787 DOI: 10.3389/fphar.2021.775126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background: There is controversy over whether use of new oral anticoagulants (NOACs) associates with increased hemorrhage risk compared with non-NOAC. Meanwhile, determining which NOAC to use remains unclear. We aimed to summarize the evidence about NOACs in venous thromboembolism (VTE) prevention for patients with total hip and knee arthroplasty (THA and TKA). Methods: We searched RCTs assessing NOACs for VTE prophylaxis in adults undergoing THA and TKA in Medline, Embase, and Cochrane up to May 2021. Primary outcomes were VTE [included deep vein thrombosis (DVT) and pulmonary embolism (PE)], major VTE, and major bleeding. The rank probabilities of each treatment were summarized by the surface under the cumulative ranking curve area (SUCRA). Results: 25 RCTs with 42,994 patients were included. Compared with non-NOAC, NOACs were associated with a decreased risk of VTE (RR 0.68; 95% CI 0.55–0.84) and major VTE (RR = 0.52; 95% CI 0.35–0.76). Additionally, rivaroxaban, apixaban, and edoxaban but not dabigatran and betrixaban, did confer a higher efficacy compared with non-NOAC. None of the individual NOACs increased the risk of bleeding, while apixaban and betrixaban were even associated with a decreased risk of bleeding. In the comparison of different NOACs, rivaroxaban was associated with the greatest benefits in VTE (SUCRA = 79.6), DVT (SUCRA = 88.8), and major VTE (SUCRA = 89.9) prevention. Furthermore, subgroup analysis confirmed that NOACs associated with a higher efficacy tendency in patients with follow-up duration <60 days than follow-up duration ≥60 days. Conclusion: Evidence suggests that NOACs exert more benefits on VTE prophylaxis, and none of the individual NOACs increased hemorrhage compared with non-NOAC. Among various NOACs, rivaroxaban is recommended in patients with lower bleeding risk, and apixaban is recommended in patients with higher bleeding risk. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021266890].
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Affiliation(s)
- Yi-Hu Yi
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Song Gong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tian-Lun Gong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling-Yun Zhou
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Can Hu
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei-Hua Xu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Wang S, Liu Y, Wang L, Zuo H, Tian Y, Wang Y, Yin D, Zhang H, Tian Y. Optimisation of oral anticoagulants for patients with atrial fibrillation within 12 months after percutaneous coronary intervention: A meta-analysis and systematic review. IJC HEART & VASCULATURE 2021; 36:100850. [PMID: 34401468 PMCID: PMC8349768 DOI: 10.1016/j.ijcha.2021.100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal antithrombotic strategy, especially regarding oral anticoagulants (OACs) for atrial fibrillation (AF) patients with bleeding and thrombosis risk after percutaneous coronary intervention (PCI), remains unknown. This study explored the optimal oral anticoagulants for AF patients after PCI using a meta-analysis. METHODS Randomised controlled trials were identified from PubMed, Embase, and the Cochrane Library through December 2020. Risk ratios, 95% confidence intervals, and random-effects models were used to compare different antithrombotic strategies through network meta-analysis, and the combination of antithrombotic agents was ranked according to the surface under the cumulative ranking curve and rankograms. Interval plots were drawn to observe pairwise comparisons between the different strategies. RESULTS Five studies of 11,532 patients were included. Factor IIa inhibitor 110 mg bid plus a P2Y12 inhibitor had the greatest advantage for reducing Thrombolysis In Myocardial Infarction (TIMI) major or minor bleeding; Factor Xa inhibitor plus a P2Y12 inhibitor had the greatest advantage for reducing International Society on Thrombosis and Hemostasis major bleeding. For patients at risk of stroke plus all-cause death, factor IIa inhibitor 150 mg bid plus a P2Y12 inhibitor should be prioritised, and for those at risk of myocardial infarction and stent thrombosis, vitamin K antagonists plus a P2Y12 inhibitor were preferred. CONCLUSION Factor IIa inhibitor 110 mg, factor IIa inhibitor 150 mg, factor Xa inhibitor and vitamin K antagonists should be selected in different situations.
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Key Words
- 95% CI, 95% confidence intervals
- AF, Atrial fibrillation
- Antithrombotic therapy
- Atrial fibrillation
- DAT, Oral anticoagulants plus single antiplatelet therapy
- IIa, Factor IIa
- ISTH, International Society on Thrombosis and Hemostasis
- MI, Myocardial infarction
- NOACs, Novel oral anticoagulants
- OACs, Oral anticoagulants
- Oral anticoagulant
- PCI, Percutaneous coronary intervention
- Percutaneous coronary intervention
- RR, Risk ratios
- SD, Standard deviation
- SUCRA, Surface under the cumulative ranking curve
- TAT, Vitamin K antagonist plus a P2Y12 inhibitor and aspirin
- TIMI, Thrombolysis In Myocardial Infarction
- VKA, Vitamin K antagonist
- Xa, Factor Xa
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Affiliation(s)
- Shuo Wang
- Department of Pathophysiology and Key Laboratory of Cardiovascular Pathophysiology, Harbin Medical University, Key Laboratory of Cardiovascular Research (Harbin Medical University), Ministry of Education, Harbin 150086, PR China
- Heilongjiang Academy of Medical Sciences, Harbin, China
| | - Ying Liu
- Heilongjiang Academy of Medical Sciences, Harbin, China
- Department of Cardiology, The First Affiliated Hospital, Cardiovascular Institute, Harbin Medical University, Harbin 150001, PR China
| | - Linxin Wang
- Heilongjiang Academy of Medical Sciences, Harbin, China
- Department of Cardiology, The First Affiliated Hospital, Cardiovascular Institute, Harbin Medical University, Harbin 150001, PR China
| | - Haiqi Zuo
- Heilongjiang Academy of Medical Sciences, Harbin, China
- Department of Cardiology, The First Affiliated Hospital, Cardiovascular Institute, Harbin Medical University, Harbin 150001, PR China
| | - Yanfeng Tian
- Department of Cardiology, The First Affiliated Hospital, Cardiovascular Institute, Harbin Medical University, Harbin 150001, PR China
| | - Yimeng Wang
- Department of Pathophysiology and Key Laboratory of Cardiovascular Pathophysiology, Harbin Medical University, Key Laboratory of Cardiovascular Research (Harbin Medical University), Ministry of Education, Harbin 150086, PR China
- Heilongjiang Academy of Medical Sciences, Harbin, China
| | - Dechun Yin
- Department of Cardiology, The First Affiliated Hospital, Cardiovascular Institute, Harbin Medical University, Harbin 150001, PR China
| | - Haiyu Zhang
- Department of Cardiology, The First Affiliated Hospital, Cardiovascular Institute, Harbin Medical University, Harbin 150001, PR China
| | - Ye Tian
- Department of Pathophysiology and Key Laboratory of Cardiovascular Pathophysiology, Harbin Medical University, Key Laboratory of Cardiovascular Research (Harbin Medical University), Ministry of Education, Harbin 150086, PR China
- Heilongjiang Academy of Medical Sciences, Harbin, China
- Department of Cardiology, The First Affiliated Hospital, Cardiovascular Institute, Harbin Medical University, Harbin 150001, PR China
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Casula M, Fortuni F, Ferlini M, Fabris F, Oltrona Visconti L, Leonardi S. Meta-Analysis Comparing Potent Oral P2Y 12 Inhibitors versus Clopidogrel in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Am J Cardiovasc Drugs 2021; 21:231-240. [PMID: 32895853 PMCID: PMC7956939 DOI: 10.1007/s40256-020-00436-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In patients with atrial fibrillation (AF) receiving percutaneous coronary intervention (PCI), current guidelines recommend against combining potent oral P2Y12 inhibitors (i.e. ticagrelor or prasugrel) with oral anticoagulant (OAC) therapy, but the evidence is limited. OBJECTIVE The aim of this meta-analysis was to compare the efficacy and safety of potent oral P2Y12 inhibitors with clopidogrel in patients receiving OAC therapy for AF after a recent PCI. METHODS Electronic databases were searched for randomized controlled trials (RCT) reporting outcomes according to the P2Y12 inhibitor used. Major or clinically relevant non-major bleeding were the safety endpoints, while the efficacy outcomes were major adverse cardiovascular events (MACE). The potent oral P2Y12 inhibitors prasugrel and ticagrelor were compared with clopidogrel. A subgroup analysis was conducted to evaluate the differences between patients treated with dual antithrombotic therapy (DAT) versus triple antithrombotic therapy (TAT). RESULTS Four RCTs that included 10,057 patients were included in this analysis. Potent oral P2Y12 inhibitors were associated with a significant increase in major or clinically relevant non-major bleeding compared with clopidogrel (risk ratio [RR] 1.30, 95% confidence interval [CI] 1.06-1.59, p = 0.01; number needed to harm 18, 95% CI 12-36). This finding was consistent regardless of the concomitant antithrombotic therapy (DAT vs. TAT; p = 0.69). The risk of MACE did not differ between potent oral P2Y12 inhibitors and clopidogrel (RR 1.02, 95% CI 0.57-1.82). CONCLUSIONS In patients receiving OAC therapy for AF after a recent PCI, potent oral P2Y12 inhibitors increase the risk of clinically relevant bleeding compared with clopidogrel, with no evident benefit in terms of MACE reduction.
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Affiliation(s)
- Matteo Casula
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy.
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.
| | - Federico Fortuni
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Fabris
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Luigi Oltrona Visconti
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sergio Leonardi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Al Said S, Kaier K, Nury E, Alsaid D, Meder B, Gibson CM, Bax J, Meerpohl JJ, Katus H. Non-vitamin K antagonist oral anticoagulants (NOACs) after transcatheter aortic valve replacement (TAVR): a network meta-analysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Samer Al Said
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics; Faculty of Medicine and Medical Center, University of Freiburg; Freiburg Germany
| | - Edris Nury
- Institute for Evidence in Medicine, Medical Center - University of Freiburg; Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Dima Alsaid
- Institute for Evidence in Medicine, Medical Center - University of Freiburg; Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Benjamin Meder
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
| | - C. Michael Gibson
- Cardiology Division, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Jeroen Bax
- Department of Cardiology; Leiden University Medical Center; Leiden Netherlands
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Hugo Katus
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
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