Safety and efficacy of dual versus triple antithrombotic therapy in Patients with atrial fibrillation undergoing percutaneous coronary intervention: a meta-analysis

Abdelmoniem Moustafa; Mohammad Khan; Marei Saud; Alsamman Mohd Abdalla; Baig Amer; Saad Muhammad

doi:10.4103/ajm.ajm_40_20

Avicenna Journal of Medicine, Table of Contents

CC BY-NC-ND 4.0 · Avicenna J Med 2020; 10(04): 232-240
DOI: 10.4103/ajm.ajm_40_20

Original Article

Safety and efficacy of dual versus triple antithrombotic therapy in Patients with atrial fibrillation undergoing percutaneous coronary intervention: a meta-analysis

Abdelmoniem Moustafa

Department of Internal Medicine, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA

,

Mohammad Khan

Department of Internal Medicine, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA

,

Marei Saud

Department of Cardiac Surgery, Duesseldorf University Hospital, Düsseldorf, Germany

,

Alsamman Mohd Abdalla

Department of Internal Medicine, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA

,

Baig Amer

Department of Internal Medicine, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA

,

Saad Muhammad

Department of Cardiology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA

› Author Affiliations
Subject Editor:

Abstract

Background: Patients with atrial fibrillation undergoing percutaneous coronary intervention have indications for oral anticoagulation and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor. The concurrent use of all three agents, termed triple oral antithrombotic therapy (TAT), increases the risk of bleeding. A number of prospective trials showed that the omission of aspirin mitigates the risk of bleeding without affecting major adverse cardiovascular event (MACE). Materials and Methods: The databases of PubMed, Embase, and Cochrane Central databases were searched from inception to October 2019. Relevant randomized control trials comparing dual antithrombotic therapy (DAT) versus TAT were identified and a metanalysis was performed using random-effect model. The safety endpoints of interest were thrombolysis in myocardial infarction criteria (TIMI) major and minor bleeding, TIMI major bleeding, and intracranial bleeding. The efficacy endpoints of interest were MACE and individual components of MACE. Results: Six trials with 11,722 patients were included. For safety endpoint, DAT was associated with significantly lower incidence of TIMI major and minor bleeding [RR: 0.58, 95% CI 0.44–0.77, P = 0.0001], TIMI major bleeding [RR: 0.55, 95% CI 0.42–0.73, P < 0.0001] as well as intracranial bleeding [RR: 0.35, 95% CI 0.16–0.73, P = 0.006] compared with TAT. No significant difference was observed for MACE [RR: 0.96 (0.79–1.17) P = 0.71] or any of the individual components of MACE between the two groups. Conclusion: Omission of aspirin from TAT in patients with Atrial Fibrillation (AF) after percutaneous coronary intervention is associated with lower risk of bleeding without compromising the efficacy in terms of mortality and cardiovascular thrombotic events.

Keywords

Atrial fibrillation - CAD - coronary artery disease - dual antithrombotic therapy - stent - triple antithrombotic therapy

Full Text

References

References
1 Nieuwlaat R, Capucci A, Camm AJ, Olsson SB, Andresen D, Davies DW. et al European Heart Survey Investigators. Atrial fibrillation management: A prospective survey in ESC member countries: The euro heart survey on atrial fibrillation. Eur Heart J 2005; 26: 2422-34
2 Nabauer M, Gerth A, Limbourg T, Schneider S, Oeff M, Kirchhof P. et al. The registry of the German competence network on atrial fibrillation: Patient characteristics and initial management. Europace 2009; 11: 423-34
3 Moustafa A, Ruzieh M, Eltahawy E, Karim S. Antithrombotic therapy in patients with atrial fibrillation and coronary artery disease. Avicenna J Med 2019; 9: 123-8
4 January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland Jr JC. et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic surgeons. Circulation 2019; 140: e125-51
5 Khurram Z, Chou E, Minutello R, Bergman G, Parikh M, Naidu S. et al. Combination therapy with aspirin, clopidogrel and warfarin following coronary stenting is associated with a significant risk of bleeding. J Invasive Cardiol 2006; 18: 162-4
6 Waldo AL. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): A randomised controlled trial. In: Yearbook of Cardiology. 2007: 423-4
7 Asencio LA, Huang JJ, Alpert JS. Combining antiplatelet and antithrombotic therapy (triple therapy): What are the risks and benefits?. Am J Med 2014; 127: 579-85
8 Faxon DP, Eikelboom JW, Berger PB, Holmes DR, Bhatt DL, Moliterno DJ. et al. Antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. Circ Cardiovas Interv 2011; 4: 522-34
9 Dewilde WJM, Oirbans T, Verheugt FWA, Kelder JC, De Smet BJ, Herrman J-P. et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: An open-label, randomised, controlled trial. Lancet 2013; 381: 1107-15
10 Vranckx P, Valgimigli M, Eckardt L, Tijssen J, Lewalter T, Gargiulo G. et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): A randomised, open-label, phase 3b trial. Lancet 2019; 394: 1335-43
11 Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S. et al GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490
12 Fiedler KA, Maeng M, Mehilli J, Schulz-Schüpke S, Byrne RA, Sibbing D. et al. Duration of triple therapy in patients requiring oral anticoagulation after drug-eluting stent implantation: The ISAR-TRIPLE trial. J Am Coll Cardiol 2015; 65: 1619-29
13 Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T. et al RE-DUAL PCI Steering Committee and Investigators. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med 2017; 377: 1513-24
14 Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P. et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med 2016; 375: 2423-34
15 Lopes RD, Heizer G, Aronson R, Vora AN, Massaro T, Mehran R. et al AUGUSTUS Investigators. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med 2019; 380: 1509-24
16 Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345 (07) 494-502 [erratum appears in N Engl J Med 2001 Dec 6;345(23):1716; Nov 15;345(20):1506].
17 Wijns W, Kolh P, Danchin N, Mario CD, Falk V, Folliguet T. European Association for Percutaneous Cardiovascular Interventions EA. The task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2010; 31: 2501-55
18 Amsterdam EA, Wenger NK, Brindis RG, Casey Jr DE, Ganiats TG, Holmes Jr DR. et al ACC/AHA Task Force Members; Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: Executive summary: A report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation 2014; 130: 2354-94
19 Connolly S, Pogue J, Hart R, Pfeffer M, Hohnloser S, Chrolavicius S. ACTIVE Writing Group of the ACTIVE Investigators. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): A randomised controlled trial. Lancet 2006; 367: 1903-12
20 Rogacka R, Chieffo A, Michev I, Airoldi F, Latib A, Cosgrave J. et al. Dual antiplatelet therapy after percutaneous coronary intervention with stent implantation in patients taking chronic oral anticoagulation. JACC Cardiovasc Interv 2008; 1: 56-61
21 Golwala HB, Cannon CP, Steg PG, Doros G, Qamar A, Ellis SG. et al. Safety and efficacy of dual versus. Triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: A systematic review and meta-analysis of randomized clinical trials. Eur Heart J 2018; 39: 1726-35a
22 Lopes RD, Hong H, Harskamp RE, Bhatt DL, Mehran R, Cannon CP. et al. Safety and efficacy of antithrombotic strategies in patients with atrial fibrillation undergoing percutaneous coronary intervention: A network meta-analysis of randomized controlled trials. JAMA Cardiol 2019; 4: 747-55
23 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin 3rd JP, Guyton RA. et al American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2014; 63: e57-185
24 January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland Jr JC. et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the heart rhythm society. J Am Coll Cardiol 2019; 74: 104-32
25 Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B. et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Rev Esp Cardiol (Engl Ed) 2017; 70: 50
26 Lu W, Chen L, Wang Y, Yao Y, Fu C, Zuo P. et al. Rationale and design of MANJUSRI trial: A randomized, open-label, active-controlled multicenter study to evaluate the safety of combined therapy with ticagrelor and warfarin in AF subjects after PCI-eS. Contemp Clin Trials 2015; 40: 166-71

Supplementary Material

Supplementary Material