Efficacy and safety of triple versus dual antithrombotic therapy in atrial fibrillation and ischemic heart disease: a systematic review and meta-analysis

Abstract

The optimal antithrombotic regimen for patients with atrial fibrillation and ischemic heart disease remains unclear. Therefore, we aimed to compare the efficacy and safety of triple therapy (TT [an anticoagulant and 2 antiplatelet drugs]) with dual therapy (DAPT [2 antiplatelet drugs] or DT [an anticoagulant and a single antiplatelet drug]) in patients with atrial fibrillation and ischemic heart disease. We systematically searched the Cochrane Library, PubMed and Embase databases for all relevant studies up to August 2017. The overall risk estimates were calculated using the random-effects model. A total of 17 observational studies were included. Regarding the efficacy outcomes, no differences were observed between the triple therapy and the dual therapy for all-cause death, cardiovascular death, or thrombotic complications (i.e., acute coronary syndrome, stent thrombosis, thromboembolism/stroke, and major adverse cardiac and cerebrovascular events). Regarding the safety outcomes, compared with DAPT, TT was associated with increased risks of major bleeding (a relative risk of 1.96 [1.40–2.74]), minor bleeding (1.69 [1.06–2.71]) and overall bleeding (1.80 [1.23–2.64]). Compared wtih DT, TT was associated with a greater risk of major bleeding (1.65 [1.23–2.21]), but rates of minor bleeding (0.99 [0.56–1.77]) and overall bleeding (1.14 [0.76–1.71]) were similar. Overall, TT confers an increased hazard of major bleeding with no thromboembolic protection compared with dual therapy in patients with atrial fibrillation and ischemic heart disease.

Antithrombotic Therapy for Atrial Fibrillation

“…Broadly similar conclusions were drawn from the systematic review and meta-analysis (17 studies, 104,639 patients) by Zhu et al 281 where triple therapy (DAPT þ OAC) was associated with an increased risk of bleeding compared with DAPT alone, with no differences observed between triple therapy and the dual therapy for all-cause death, cardiovascular death, or thrombotic complications (ie, ACS, stent thrombosis, thromboembolism/stroke, and major adverse cardiac and cerebrovascular events). In both systematic reviews, there was marked heterogeneity in study size, patient population, intervention types, stent use, etc.…”

Ischemic and bleeding outcomes of triple therapy in patients on chronic anticoagulation undergoing percutaneous coronary intervention: A meta-analysis of randomized trials

“…The findings of this meta-analysis are similar to the result of several observational studies 17–19 and published meta-analyses of those studies. 20,21 An important finding of our study is no difference in thrombotic and thromboembolic events between triple and dual therapy. One hypothesis of comparable ischemic outcomes between the groups could be direct or indirect thrombin inhibition by OAC, 22 which can potentially provide cardio-protection against ischemic events/thromboembolism.…”

Antithrombotic Strategies in Patients with Atrial Fibrillation Following Percutaneous Coronary Intervention: A Systemic Review and Network Meta-Analysis of Randomized Controlled Trials

“…Most of the meta-analyses regarding VKA and P2Y 12 inhibitors with and without aspirin have demonstrated that dual therapy is associated with a similar risk of bleeding complications and a similar risk of MACEs compared to triple therapy. However, the study by Zhu et al found that dual therapy had a significantly reduced (40% lower) bleeding risk compared to triple therapy [20]. These data suggest that dual therapy with VKA and P2Y 12 inhibitors is more favored than standard triple therapy with VKA, P2Y 12 inhibitors, and aspirin, and that standard triple therapy should be avoided in such patients.…”

“…Current guidelines recommend a short course of triple antithrombotic therapy, including OAC and DAPT, in patients with OAC indication who are undergoing PCI [18]. Several meta-analyses comparing the safety and efficacy of dual and triple antithrombotic therapies in these high risk patients are summarized in Table 1 [13][14][15][19][20][21][22][23][24][25][26]. The network meta-analysis performed by Gong et al showed that the combination of VKA with single antiplatelet therapy (SAPT) yielded the best safety and efficacy, with a very low dose of rivaroxaban and DAPT deemed to be an acceptable alternative to standard triple therapy with VKA and DAPT [21].…”