ARTICLE: Dual Versus Triple Therapy for Atrial Fibrillation After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

AUTHORS: Safi U. Khan, Mohammed Osman, Muhammad U. Khan, Muhammad Shahzeb Khan, Di Zhao, Mamas A. Mamas, Nazir Savji, Ahmad Al-Abdouh, Rani K. Hasan, Erin D. Michos

JOURNAL: Ann Intern Med. 2020 Mar 17. doi: 10.7326/M19-3763. [Epub ahead of print]

Abstract

BACKGROUND: The safety and effectiveness of dual therapy (direct oral anticoagulant [DOAC] plus P2Y12 inhibitor) versus triple therapy (vitamin K antagonist plus aspirin and P2Y12 inhibitor) in patients with nonvalvular atrial fibrillation (AF) after percutaneous coronary intervention (PCI) is unclear.

PURPOSE: To examine the effects of dual versus triple therapy on bleeding and ischemic outcomes in adults with AF after PCI.

DATA SOURCES: Searches of PubMed, EMBASE, and the Cochrane Library (inception to 31 December 2019) and ClinicalTrials.gov (7 January 2020) without language restrictions; journal Web sites; and reference lists.

STUDY SELECTION: Randomized controlled trials that compared the effects of dual versus triple therapy on bleeding, mortality, and ischemic events in adults with AF after PCI.

DATA EXTRACTION: Two independent investigators abstracted data, assessed the quality of evidence, and rated the certainty of evidence.

DATA SYNTHESIS: Four trials encompassing 7953 patients were selected. At the median follow-up of 1 year, high-certainty evidence showed that dual therapy was associated with reduced risk for major bleeding compared with triple therapy (risk difference [RD], -0.013 [95% CI, -0.025 to -0.002]). Low-certainty evidence showed inconclusive effects of dual versus triple therapy on risks for all-cause mortality (RD, 0.004 [CI, -0.010 to 0.017]), cardiovascular mortality (RD, 0.001 [CI, -0.011 to 0.013]), myocardial infarction (RD, 0.003 [CI, -0.010 to 0.017]), stent thrombosis (RD, 0.003 [CI, -0.005 to 0.010]), and stroke (RD, -0.003 [CI, -0.010 to 0.005]). The upper bounds of the CIs for these effects were compatible with possible increased risks with dual therapy.

LIMITATION: Heterogeneity of study designs, dosages of DOACs, and types of P2Y12 inhibitors.

CONCLUSION: In adults with AF after PCI, dual therapy reduces risk for bleeding compared with triple therapy, whereas its effects on risks for death and ischemic end points are still unclear.

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