Antithrombotic regimen for patients with cardiac indication for dual antiplatelet therapy and anticoagulation: a meta-analysis of randomized trials

Abstract

Objectives The optimal antithrombotic strategy for patients with a long-term indication for anticoagulation and acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remains controversial. This meta-analysis aims to compare randomised trials’ outcomes of these patients, focussing on dual versus triple antithrombotic and non vitamin K oral anticoagulants (NOACs) versus vitamin K oral anticoagulants regimens. Methods Medline, Embase and Cochrane databases were searched from January 1980 to March 2019 yielding 309 articles, and after careful screening, five randomized trials totalling 10\u2009643 patients were included for analysis. Results Dual antithrombotic regimens were associated with significantly less thrombolysis in myocardial infarction (TIMI) major and minor bleeding [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.40–0.71], with no significant difference in major adverse cardiovascular events (OR 0.93, 95% CI 0.72–1.22) or all-cause mortality (OR 0.89, 95% CI 0.61–1.19). NOAC regimens had significantly lower TIMI major and minor bleeding (OR 0.58, 95% CI 0.43–0.78) and intracranial bleeding (OR 0.33, 95% CI 0.16–0.66), with similar rates of major adverse cardiovascular events (OR 1.00, 95% CI 0.86–1.16) and all-cause mortality (OR 1.01, 95% CI 0.81–1.26). Conclusion Dual antithrombotic and NOAC regimens have reduced bleeding without compromising the risk of cardiovascular events or mortality, and should be preferred for patients with ACS or PCI also needing long-term anticoagulation.