Safety and efficacy of direct oral anticoagulants compared to Vitamin K antagonists postpercutaneous coronary interventions in patients with atrial fibrillation: A systematic review and meta‐analysis

Abstract

Background Atrial fibrillation (AF) and coronary artery disease (CAD) are commonly associated. Cotreatment with multiple antithrombotic agents can increase the risk of bleeding. We sought to evaluate patient‐centered outcomes in patients with AF on double therapy with direct oral anticoagulants (DOACs) compared to patients with standard triple therapy, [a vitamin K antagonist (VKA) plus dual antiplatelet therapy]. Methods We performed a literature search of randomized controlled trials (RCTs) reporting outcomes of patients receiving double therapy with DOACs compared to triple therapy with VKAs in patients with AF undergoing percutaneous coronary intervention (PCI). Patient‐centered outcomes were the International Society of Thrombosis and Hemostasis (ISTH) major or clinically relevant nonmajor bleeding (CRNB), all‐cause mortality, major adverse cardiovascular events (MACE), stent thrombosis, myocardial infarction, and stroke. Results Four RCTs (9602 patients) met our inclusion criteria. Compared to VKAs, DOACs were associated with significantly lower ISTH major bleeding/ CRNB (RR: 0.75, 95% CI: 0.67‐0.82, P < .00001, I2 = 11%). There were no statistically significant differences in the efficacy outcomes, including myocardial infarction (RR: 0.99, 95% CI :0.79‐1.25, P = .96), stent thrombosis (RR: 0.97, 95% CI: 0.6‐1.55, P = .89), ischemic stroke (RR: 0.76, 95% CI: 0.5‐1.15, P = .19), all‐cause mortality (RR: 1.06, 95% CI: 0.85‐1.31, P = .61), and MACE (RR: 1.06, 95% CI: 0.91‐1.22, P = .97). Conclusion Compared with triple therapy with VKAS, double therapy with DOACs is associated with a reduced risk of bleeding and is as effective in patients with AF undergoing PCI.

Three types of antithrombotic therapy in atrial fibrillation patients undergoing percutaneous coronary intervention: a meta-analysis and systematic review

“…On the other hand, as compared with TAT, which prompted a high incidence rate of bleeding events, DAT reduced the risk of TIMI major bleeding by 59% and that of ISTH major bleeding by 39%. This finding was similar to conclusion in previous meta-analysis [8,9,10].…”

“…Agasthi et al [8] conducted a meta-analysis to explore the safety and efficacy of NOAC and VKA, but the randomized controlled trials included in their study were designed to compare NOAC plus a P2Y12 inhibitor and VKA plus a P2Y12 inhibitor and aspirin; that omitting the effect of aspirin made the study conclusions less clinically relevant. Potpara, et al [9] performed a meta-analysis to assess the different effects when applying antithrombotic therapy consisting of aspirin or not in patients with AF and coronary stents.…”

“…The previous meta-analysis [8,9,10] identified that triple antithrombotic therapy (TAT) increases bleeding events relative to dual antithrombotic therapy (DAT), while NOAC decreases the risk of bleeding events as compared with VKA. However, the results of comparisons between DAT and TAT or NOAC and VKA may be more ambiguous than this.…”