What is the optimal antithrombotic regimen in terms of major bleeding and ischemic risk for patients with atrial fibrillation undergoing percutaneous coronary intervention?
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.
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.
Antithrombotic treatment in patients with atrial fibrillation (AF) and percutaneous coronary intervention (PCI) presents a balancing act with regard to bleeding and ischemic risks.
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.
Online computerized database (MEDLINE).
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).
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.
Lopes RD, Hong H, Harskamp RE, et al. Optimal Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: An Updated Network Meta-analysis. JAMA Cardiol. Published online February 26, 2020. doi:10.1001/jamacardio.2019.6175
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