Comparing the clinical outcomes in patients with atrial fibrillation receiving dual antiplatelet therapy and patients receiving an addition of an anticoagulant after coronary stent implantation: A systematic review and meta-analysis of observational studies

Therapeutic effect of antithrombotic drug combinations in patients with atrial fibrillation undergoing percutaneous coronary intervention for coronary heart disease: a meta-analysis

OBJECTIVE

To explore suitable treatment strategies for patients with coronary heart disease and atrial fibrillation after percutaneous coronary intervention (PCI) via systematically analyzing and comparing the clinical efficacy of dual antithrombotic therapy (DAT) and triple antithrombotic therapy (TAT).

METHODS

Pubmed, Embase and Cochrane Library databases were searched. The literature from the database establishment to August 2022 was reviewed by 2 researchers separately according to the inclusion and exclusion criteria and the method recommended by the Cochrane Collaboration. The data was extracted for quality assessment. The primary endpoints of the study were safety endpoints and efficacy endpoints, the former includes major bleeding events and the latter includes mortality, myocardial infarction, stent thrombosis and stroke. RevMan5.4 software was used for meta-analysis.

RESULTS

There were 11 studies were included for the meta-analysis, 5 observational studies and 6 randomized controlled trials. The number of patients included was 2,4032, of which 13818 (57.5%) received DAT and 9483 (39.5%) received TAT. Our analyses indicated that compared with TAT treatment, DAT significantly reduced the incidence of major bleeding (OR=0.71, 95% CI [0.61, 0.83], P<0.0001) and the incidence of minor bleeding (OR=0.61, 95% CI [0.50, 0.75], P<0.00001). Subgroup analysis showed that DAT with novel oral anticoagulants (NOACs) reduced major bleeding (OR=0.64, 95% CI [0.54, 0.76], P<0.00001) and the incidence of minor bleeding (OR=0.56, 95% CI [0.45, 0.69], P<0.00001), but DAT with vitamin K antagonists (VKAs) was not significantly different from TAT in major bleeding (OR=1.20, 95% CI [0.82, 1.75], P=0.35) and minor bleeding (OR=1.15, 95% CI [0.64, 2.05], P=0.64).

CONCLUSIONS

DAT with NOACs has a higher safety profile against bleeding in patients with atrial fibrillation after PCI. DAT with VKAs was similar to TAT in terms of antithrombotic effect and incidence of bleeding.

Comparison of early clinical outcomes between dual antiplatelet therapy and triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention

Background and objective

Most Asian patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) receive only dual antiplatelet therapy (DAPT) without oral anticoagulants (vitamin K antagonists [VKA] or non-VKA oral anticoagulants [NOAC]). However, it has not been fully investigated whether the DAPT results in better clinical outcomes in the early period after PCI than the standard triple therapy with VKA or NOAC.

Methods

We analyzed the claims records of 11,039 Korean AF population who had PCI between 2013 and 2018. Patients were categorized according to the post-PCI antithrombotic therapy as VKA-based triple therapy (VKA-TT), NOAC-based triple therapy (NOAC-TT), and DAPT groups. After baseline adjustment using inverse probability weighting, we compared the risks of ischemic endpoints (ischemic stroke, myocardial infarction, and all-cause mortality) and major bleeding at 3 months post-PCI.

Results

Ischemic stroke, MI, and all-cause mortality occurred in 105, 423, and 379 patients, respectively, and 138 patients experienced major bleeding. The DAPT group was associated with a lower risk of ischemic stroke and major bleeding (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37–0.84) compared to the VKA-TT group, despite no significant differences in the risks of MI and all-cause mortality. In contrast, the DAPT group demonstrated no significant difference in the risks for ischemic endpoints compared to the NOAC-TT group. Additionally, the DAPT group had a numerically lower risk of major bleeding than the NOAC-TT group but this was not statistically significant (HR 0.69, 95% CI 0.45–1.07).

Conclusions

An outcome benefit of DAPT was observed in the early period after PCI compared to the VKA-TT, but not against NOAC-TT users among the Asian AF population. Given the potential long-term benefits of NOACs, greater efforts should be made to increase compliance in clinical practice with proper combination therapy with NOAC after PCI.

Increased bleeding events with the addition of apixaban to the dual anti-platelet regimen for the treatment of patients with acute coronary syndrome: A meta-analysis

BACKGROUND

Dual anti-platelet therapy (DAPT) with aspirin and clopidogrel has been the mainstay of treatment for patients with acute coronary syndrome (ACS). However, the recurrence of thrombotic events, potential aspirin and clopidogrel hypo-responsiveness, and other limitations of DAPT have led to the development of newer oral anti-thrombotic drugs. Apixaban, a new non-vitamin K antagonist, has been approved for use. In this meta-analysis, we aimed to compare the bleeding outcomes observed with the addition of apixaban to DAPT for the treatment of patients with ACS.

METHODS

Online databases including EMBASE, Cochrane Central, http://www.ClinicalTrials.gov, MEDLINE and Web of Science were searched for English based publications comparing the use of apixaban added to DAPT for the treatment of patients with ACS. Different categories of bleeding events and cardiovascular outcomes were assessed. The analysis was carried out by the RevMan software version 5.4. Odds ratios (OR) with 95% confidence intervals (CI) were used to represent the data following analysis.

RESULTS

This research analysis consisted of 4 trials with a total number of 9010 participants. Thrombolysis in myocardial infarction (TIMI) defined major bleeding (OR: 2.45, 95% CI: 1.45-4.12; P = .0008), TIMI defined minor bleeding (OR: 3.12, 95% CI: 1.71-5.70; P = .0002), International society of thrombosis and hemostasis (ISTH) major bleeding (OR: 2.49, 95% CI: 1.80-3.45; P = .00001) and Global Use of Strategies to Open Occluded Arteries (GUSTO) defined severe bleeding (OR: 3.00, 95% CI: 1.56-5.78; P = .01) were significantly increased with the addition of apixaban to DAPT versus DAPT alone in these patients with ACS. However fatal bleeding (OR: 10.96, 95% CI: 0.61-198.3; P = .11) was not significantly different.

CONCLUSIONS

Addition of the novel oral anticoagulant apixaban to the DAPT regimen significantly increased bleeding and therefore did not show any beneficial effect in these patients with ACS. However, due to the extremely limited data, we apparently have to rely on future larger studies to confirm this hypothesis.

Antithrombotic therapy in coronary artery disease patients with atrial fibrillation

Background

Coronary artery disease (CAD) and atrial fibrillation (AF) frequently coexist in clinical practice, making it challenging for the treating physician to choose anticoagulation and antiplatelet therapies. The aim of this study was to investigate antithrombotic strategies and assess related adverse outcomes in stable coronary artery disease (SCAD) and acute coronary syndrome (ACS) patients with AF when the CHA₂DS₂-VASc score was ≥2.

Methods

We performed a retrospective study and collected data from a computer-based patient record management system in Zhengzhou University People’s Hospital in China. In total, 2978 patients with a hospital discharge diagnosis of CAD and concomitant AF who met the inclusion criteria were enrolled from January 1, 2012 to December 31, 2016, and data from 2050 patients were finally analysed. The χ² test was used to compare the incidences of clinical endpoints between the SCAD+AF group and the ACS + AF group. Multivariable Cox regression analysis was performed to identify independent predictive factors of adverse outcomes in both groups.

Results

Oral anticoagulant (OAC) monotherapy was the most common antithrombotic therapy in SCAD+AF patients (49.55%), while double antiplatelet therapy (DAPT) was the most common treatment in ACS + AF patients (54.19%) at discharge. OAC monotherapy significantly increased and the use of single antiplatelet therapy (SAPT) decreased during follow-up (34 ± 13 months) when compared to their use at discharge in the SCAD+AF group (all p < 0.001). In the ACS + AF group, the proportion of patients using DAPT decreased notably, while the proportions of patients using SAPT and dual therapy (DT) combining OAC with SAPT increased significantly during follow-up (all p < 0.001) compared to the proportions at discharge. According to multivariable Cox regression analysis, age, hypertension and prior stroke were independent risk factors for ischaemic stroke in the SCAD+AF group and ACS + AF group (all p < 0.05). OAC was an independent protective factor for ischaemic stroke in both groups (all p < 0.05). Previous bleeding independently increased the risk of haemorrhage in both groups (all p < 0.01).

Conclusions

In this study, the proportion of anticoagulant-antiplatelet combined therapy was low in ACS + AF patients with high stroke risk. In clinical practice, the awareness of anticoagulation needs to be strengthened regarding patients with CAD and AF.

Omission of aspirin in patients taking oral anticoagulation after percutaneous coronary intervention: a systematic review and meta-analysis

BACKGROUND

There is no consensus on optimal antiplatelet and anticoagulation therapy after coronary stenting.

METHODS

We identified randomized controlled trials (RCTs) published in PubMed, Cochrane Library, and Embase using the following keywords: 'antiplatelet', 'dual therapy', 'triple therapy', 'antithrombosis', 'indication for anticoagulation', 'percutaneous coronary intervention', and 'RCTs'. Primary safety end points were relative bleeding events, and secondary efficacy end points were major adverse cardiovascular events including stent thrombosis, death, myocardial infarction, and stroke.

RESULTS

We identified three RCTs including 5387 patients, of whom 2719 (50.5%) received dual therapy (DT) and 2668 (49.5%) received triple therapy. Relative to triple therapy, DT was associated with lower Thrombolysis in Myocardial Infarction major bleeding [risk ratio (RR): 0.58; 95% confidence interval (CI): 0.42-0.82], Thrombolysis in Myocardial Infarction minor bleeding (RR: 0.46; 95% CI: 0.34-0.62), and clinical bleeding events (RR: 0.61; 95% CI: 0.47-0.81). There was no significant difference for the secondary efficacy end point. In subgroup analyses, results were similar by sex, bleeding risk, and stent type; however, DT appeared suitable for patients aged less than 75 years but not more than or equal to 75 years, implying that there may be no ideal therapy for patients older than 75 years to balance the risk of ischemia and bleeding at the same time.

CONCLUSION

Among patients with an indication for oral anticoagulation after percutaneous coronary intervention, DT appears to be the optimal strategy.

Prevention of Stroke in Atrial Fibrillation After Coronary Stenting

Background and Purpose- The optimal antithrombotic strategy to balance thromboembolic and bleeding events, especially acute stroke, for patients with atrial fibrillation following coronary stenting remains a matter of debate. We conducted a network meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in atrial fibrillation after coronary stenting. Methods- PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials and observational studies of patients with atrial fibrillation after coronary stenting. The outcomes of interest were stroke, myocardial infarction, major adverse cardiac events, mortality, and major bleeding. A network meta-analysis was performed comparing the available antithrombotic regimens in the literature. Results- Three randomized and 15 observational studies were included, with a total of 23 478 participants. Median follow-up was 2 years. Network meta-analysis demonstrated that vitamin K antagonist plus single antiplatelet therapy or direct-acting oral anticoagulant plus single antiplatelet therapy were the most effective regimens in preventing stroke. Direct-acting oral anticoagulant regimens were associated with lower major bleeding rates than vitamin K antagonist regimens. Regimens with dual antiplatelet therapy were associated with lower rates of myocardial infarction. Vitamin K antagonist plus dual antiplatelet therapy was associated with a lower mortality and low-dose direct-acting oral anticoagulants with decreased major cardiovascular adverse events. Conclusions- Direct-acting oral anticoagulant regimens were associated with less major bleeding and major cardiovascular adverse events, but vitamin K antagonists were associated with decreased mortality and stroke. These results suggest that the decision of antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention needs to be individualized.

New-Onset Atrial Fibrillation in the Post-Primary PCI Setting: A Systematic Review

Background: Atrial fibrillation is a relatively common complication of acute myocardial infarction with significant impact on the short and long-term prognosis.

Methods: A systematic literature review was done through Pubmed and CENTRAL to extract data related to new-onset atrial fibrillation following primary PCI.

Results: Searching resulted in twenty-one matched studies. Extraction of data showed an incidence rate of new-onset atrial fibrillation (2.8%-58%). A negative impact was found on the outcomes of patients treated with primary PCI with increased short and long-term mortality and morbidity.

Conclusion: New-onset atrial fibrillation is an adverse prognostic marker in patients with acute myocardial infarction treated invasively. Preventive measures and anticoagulant therapy should be considered more intensively in this subset of patients.

Clinical Outcomes of Antithrombotic Strategies for Patients with Atrial Fibrillation After Percutaneous Coronary Intervention

Antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) remain challenging. This study aims to explore the best antithrombotic strategy for AF patients after PCI based on a network meta-analysis. This study was registered in PROSPERO (CRD42018093928). The PubMed, Cochrane, and EMBASE databases were searched to identify clinical trials concerning antithrombotic therapy for AF patients with PCI from inception to April 2018. Pairwise and network meta-analysis were conducted to compare clinical outcomes of different antithrombotic therapy. The primary endpoint was major bleeding. Fifteen studies including 16,382 patients were identified with follow-up ranging from 3 to 12 months. Non-vitamin K oral anticoagulants (NOAC) plus P2Y₁₂ inhibitor ranked first with a reduced risk of major bleeding compared with vitamin K antagonist (VKA) plus dual antiplatelet therapy (OR: 0.57, 95% CI: 0.43-0.75) but with no significant difference compared with VKA plus single platelet therapy (OR: 0.85, 95% CI: 0.62-1.16). Similar thrombotic events were evident among these groups. Subgroup analysis showed that VKA plus aspirin exhibited a similar risk of major bleeding compared with VKA plus clopidogrel (OR: 0.94, 95% CI: 0.73-1.23) but was associated with increased risks of ischaemic stroke (OR: 2.10, 95% CI: 1.33-3.32) and all-cause death (OR: 1.77, 95% CI: 1.15-2.74) versus VKA plus clopidogrel. In AF patients undergoing PCI, NOAC plus P2Y₁₂ inhibitor and VKA plus clopidogrel, but not VKA plus aspirin, were associated with reduced risk of major bleeding compared with the recommended VKA-based triple therapy, while thrombotic events were similar among these treatments.

Dual versus triple antithrombotic therapy after percutaneous coronary intervention or acute coronary syndrome in patients with indication for anticoagulation: an updated meta-analysis

BACKGROUND

For patients who have an indication for anticoagulation, it is controversial whether dual therapy with an oral anticoagulant and single antiplatelet agent can be used after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) instead of triple therapy with an oral anticoagulant and dual antiplatelet therapy.

PARTICIPANTS AND METHODS

Twelve observational studies and four clinical trials were identified from three electronic databases from their inception to December, 2017. Pooled estimates were calculated using a random-effects model for meta-analysis.

RESULTS

Compared with the triple therapy, dual therapy was associated with significantly lower risk of major bleeding [relative risk (RR), 0.63; 95% confidence interval (CI), 0.50-0.80] without statistically significant increase in major adverse cardiac events (RR, 1.04; 95% CI, 0.84-1.29), all-cause death (RR, 1.15; 95% CI, 0.77-1.71), cardiac death (RR, 1.04; 95% CI, 0.67-1.61), myocardial infarction (RR, 1.25; 95% CI, 0.98-1.59), stroke (RR, 1.27; 95% CI, 0.79-2.06), stent thrombosis (RR, 1.52; 95% CI, 0.96-2.41), and repeat revascularization (RR, 1.15; 95% CI, 0.87-1.52). Although risks of myocardial infarction and stent thrombosis were marginally higher in the dual therapy group, this trend was attenuated after excluding studies that exclusively included patients undergoing PCI for ACS, but not stable coronary artery disease.

CONCLUSION

Dual therapy may be a reasonable alternative to triple therapy after PCI in patients with indication for chronic anticoagulation. However, further studies are needed to investigate efficacy of dual therapy, especially in the patients with higher ischemic risk, such as in ACS.

Effects of atrial fibrillation on complications and prognosis of patients receiving emergency PCI after acute myocardial infarction

The effects of atrial fibrillation on complications and prognosis of patients receiving emergency percutaneous coronary intervention after acute myocardial infarction (AMI) were investigated. Eighty AMI patients treated with interventional vascular recanalization in the Affiliated Hospital of Weifang Medical University (Weifang, China) from July 2015 to October 2016 were selected, including 40 patients complicated with atrial fibrillation before operation (control group) and 40 patients without atrial fibrillation before operation (observation group). The systolic blood pressure, diastolic blood pressure, heart rate, arrhythmia and common complications after MI were compared. Changes in the coronary artery thrombolysis in myocardial infarction (TIMI) flow grade and left ventricular ejection fraction (LVEF) of patients were also recorded. Moreover, changes in brain natriuretic peptide (BNP) levels were compared. The recovery time of myocardial enzyme and total troponin in both groups was recorded. The systolic and diastolic blood pressure in the observation group were significantly higher than those in the control group (p<0.05). During the intervention, the total proportion of patients with ventricular arrhythmia, atrial arrhythmia, atrioventricular block and sinus tachycardia in the observation group was significantly lower than that in the control group (p<0.05). The total proportion of common complications after MI in the observation group was obviously lower than that in the control group (p<0.05). Coronary artery TIMI flow grades and LVEFs in the observation group were obviously higher than those in the control group. BNP levels in the observation group were significantly lower than those in the control group. The recovery time of myocardial enzyme and total troponin in the observation group was significantly earlier than that in the control group. Atrial fibrillation has a certain negative effect on the circulatory function in patients with AMI after the interventional therapy, and the proportions of arrhythmia and complications in patients after MI are increased at the same time, so the postoperative recovery of patients is slow with many complications.

Antithrombotic therapy strategies for atrial fibrillation patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis

Objective

The aim of this systematic review and network meta-analysis was to evaluate the comparative efficacy and safety of antiplatelet agents, vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).

Methods

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify clinical trials comparing antiplatelet drugs with VKA and NOACs or their combination in AF patients undergoing PCI with a mean/median follow-up of at least 12 months. A network meta-analysis was conducted to directly and indirectly compare the efficacy and safety of competitive antithrombotic regimens with a Bayesian random-effects model. Results were presented as relative risks (RRs) and 95% confidence intervals (CIs).

Results

A total of 15 studies enrolling 13,104 patients were included. Among 5 regimens, rivaroxaban 15 mg daily plus P2Y₁₂ inhibitor treatment demonstrated significant superiority over dual- and triple-antiplatelet therapies (DAPT, TT) in reducing thromboembolic events (0.64 [0.38, 0.95] and 0.68 [0.43, 0.98], respectively) but showed the maximum possibility of major bleeding risk, while VKA plus single antiplatelet therapy (SAPT) seemed the safest. Significantly less risk of major bleeding was seen in DAPT group than that in TT group (0.63 [0.39, 0.99]).

Conclusions

The present study suggests that combination of VKA and SAPT is the best choice for AF patients undergoing PCI considering both efficacy and safety. Rivaroxaban 2.5 mg twice daily plus DAPT treatment owns the highest probability to be the optimal alternative to VKA plus SAPT for these patients.