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Brief Report
February 26, 2020

Optimal Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: An Updated Network Meta-analysis

Author Affiliations
  • 1Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
  • 2Amsterdam UMC–University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
  • 3Heart & Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 4The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York
  • 5Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
  • 6Department of Cardiology and Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands
  • 7Department of Cardiology, Universitair Medisch Centrum Groningen, Groningen, the Netherlands
  • 8Deutsches Herzzentrum Munchen, Klinik fur Herz-und Kreislauferkrankungen, Ludwig-Maximilians-Universität München, Munich, Germany
  • 9Department of Cardiology and Intensive Care, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Hasselt, Belgium
  • 10Cardiology and Intensive Care Medicine, St Vincenz-Hospital, Paderborn, Germany
  • 11Cardiovascular Division, Department of Medicine, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts
  • 12Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
  • 13Department of Biostatistics and Bioinformatics, Duke University of School of Medicine, Durham, North Carolina
  • 14Associate Editor, JAMA Cardiology
JAMA Cardiol. Published online February 26, 2020. doi:10.1001/jamacardio.2019.6175
Key Points

Question  What is the optimal antithrombotic regimen in terms of major bleeding and ischemic risk for patients with atrial fibrillation undergoing percutaneous coronary intervention?

Findings  This network meta-analysis of 5 randomized controlled trials found that the use of a combination of a non-vitamin K antagonist oral anticoagulant and a P2Y12 inhibitor (discontinuing the aspirin regimen a few days after percutaneous coronary intervention) reduced bleeding complications, including intracranial bleeding, whereas the combination of a vitamin K antagonist and dual antiplatelet therapy resulted in the highest rates of bleeding. The risk of ischemic events was comparable among the 4 tested regimens.

Meaning  The findings of this study may provide a rigorous and up-to-date evaluation of the safety and efficacy of available antithrombotic strategies to aid health care professionals in making informed treatment decisions.


Importance  Antithrombotic treatment in patients with atrial fibrillation (AF) and percutaneous coronary intervention (PCI) presents a balancing act with regard to bleeding and ischemic risks.

Objectives  To evaluate the safety and efficacy of 4 antithrombotic regimens by conducting an up-to-date network meta-analysis and to identify the optimal treatment for patients with AF undergoing PCI.

Data Sources  Online computerized database (MEDLINE).

Study Selection  Five randomized studies were included (N = 11 542; WOEST, PIONEER AF-PCI, RE-DUAL PCI, AUGUSTUS, ENTRUST-AF PCI).

Data Extraction and Synthesis  The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in this network meta-analysis, in which bayesian random-effects models were applied. The data were analyzed from September 9 to 29, 2019.

Main Outcomes and Measures  The primary safety outcome was thrombolysis in myocardial infarction (TIMI) major bleeding and the primary efficacy outcome was trial-defined major adverse cardiovascular events (MACE).

Results  The total number of participants included in the study was 11 532. The mean age of the participants ranged from 70 to 72 years, 69% to 83% were male, 20% to 26% were female, and the participants were predominantly white (>90%). Compared with vitamin K antagonists (VKA) plus dual antiplatelet therapy (DAPT) (reference), the odds ratios (ORs) (95% credible intervals) for TIMI major bleeding were 0.57 (0.31-1.00) for VKA plus P2Y12 inhibitor, 0.69 (0.40-1.16) for non-VKA oral anticoagulant (NOAC) plus DAPT, and 0.52 (0.35-0.79) for NOAC plus P2Y12 inhibitor. For MACE, using VKA plus DAPT as reference, the ORs (95% credible intervals) were 0.97 (0.64-1.42) for VKA plus P2Y12 inhibitor, 0.95 (0.64-1.39) for NOAC plus DAPT, and 1.03 (0.77-1.38) for NOAC plus P2Y12 inhibitor.

Conclusions and Relevance  The findings of this study suggest that an antithrombotic regimen of VKA plus DAPT should generally be avoided, because regimens in which aspirin is discontinued may lead to lower bleeding risk and no difference in antithrombotic effectiveness. The use of a NOAC plus a P2Y12 inhibitor without aspirin may be the most favorable treatment option and the preferred antithrombotic regimen for most patients with AF undergoing PCI.