Combination of antiplatelet and anticoagulant therapy, component network meta-analysis of randomized controlled trials

Abstract

BackgroundDespite numerous randomized clinical trials (RCT), data regarding the efficacy of antiplatelet and anticoagulant combinations are still conflicting. We aimed to analyze treatment options tested in various fields of cardiovascular prevention, regarding their efficacy and bleeding risk.MethodsSystematic searches of electronic databases were conducted until June 2022. A component network meta-analysis was performed in R. Risk estimates across trials were pooled using random-effects model selecting risk ratio (RR) with 95% confidence intervals (95% CIs) as summary statistics. The primary endpoint of interest was the rate of major cardiac adverse events (MACE). Major bleeding events were assessed as main safety endpoint. Secondary outcomes included cardiovascular- and overall mortality, myocardial infarction (MI), stent thrombosis, and stroke.ResultsFifteen studies randomizing 73,536 patients were identified. The MACE risk reflected heterogeneity among the anticoagulants with dabigatran and apixaban significantly reducing the risk of MACE (RR 0.56; 95% CI 0.39–0.80 and RR 0.75; 95% CI 0.58–0.98, respectively). Vitamin K antagonist (VKA), rivaroxaban, or edoxaban did not reduced of MACE while it was associated with a significant increase of bleeding risk (RR 1.66; 3.66, and 5.47, respectively). The direct anticoagulant (DOAC) dose reduction resulted in tendencies of fewer bleeding but higher MACE risk, while combination with aspirin was followed with increased risk for bleeding, however, remained non-significant in these cases.ConclusionOur meta-analysis supports that the ischemic-bleeding balance is different among direct-acting oral anticoagulants (DOACs) while this is not significantly affected by the dose reduction approaches. Long-term aspirin treatment as part of the anticoagulant and dual antiplatelet regimen provides no ischemic benefit but may increase bleeding risk.Systematic review registration[https://www.crd.york.ac.uk/prospero/], identifier [259703].

Left Ventricular Ejection Fraction Association with Acute Ischemic Stroke Outcomes in Patients Undergoing Thrombolysis

“…In the preventive treatment of LVSD, especially in AIS patients with strong cardiovascular risk factors such as AF and IHD, newer studies support the use of combination antiplatelet and anticoagulant therapy in cardiovascular prevention [ 58 , 59 ], with some stressing the importance of antiplatelet therapy [ 60 ] and even antithrombotic therapy [ 61 ]. Admittedly, this might further increase the risk of complications, such as heightened bleeding risk, especially in the AIS patient population undergoing IV thrombolysis [ 62 ].…”

Patient-Reported Outcomes of Endovascular Treatment of Post-Thrombotic Syndrome: Ancillary Study of a French Cohort

“…In some patients, an endovascular approach cannot be performed, and surgery is mandatory to treat PTS. The selection of these patients should be optimal, particularly considering anaesthetic and surgical risks [3,10,[30][31][32][33][34][35].…”

“…Indeed, the risk of bleeding must be considered for long-term treatment. The venous regimen is different from the arterial one, with slower pressure and blood flow that can potentialize the hypercoagulability state linked to recent intervention with stent placement, particularly in patients with thrombophilia [34]. Based on empirical data and local habitus, most physicians give therapeutic anticoagulation for 2 to 6 months, followed by aspirin for a non-determined time.…”

“…Long-term therapeutic anticoagulation is typically given to patients with a hypercoagulable state requiring lifelong anticoagulation [12,32,35]. Moreover, some authors highlight the benefits of collaborative work only in complex situations, while others conclude that a daily collaborative network including angiologists and interventional practitioners seems to be the better way to improve the benefits of the patient from the procedure [34,35]. Nowadays, special attention should be given to associated measures that are mandatory to ensure good results in the long term.…”

Factor XIa Inhibitors as a Novel Anticoagulation Target: Recent Clinical Research Advances

“…Oral anticoagulants currently used in the prophylaxis and therapy of thromboembolic disorders include Apixaban, Rivaroxaban, Edoxaban, and Dabigatran, all of which inhibit proteinase Xa (FXa) and thrombin or reduce its precursors: factor X and plasma concentrations of thrombin [ 8 ]. As factor Xa and thrombin are the center in the hemostatic response to damage, these drugs increase the possibility of serious hemorrhaging in patients, particularly gastrointestinal, intracranial and life-threatening major bleeding [ 9 ]. Results of a meta-analysis of NOACs in patients with myocardial infarction suggest a large heterogeneity in the cardiovascular safety of NOACs [ 10 ].…”