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Published on: February 26, 2013
Meta-analysis of Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary
Toshiki Kuno1, Hiroki Ueyama1, Hisato Takagi2
1Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York.
Insights
For atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI), apixaban plus P2Y12 inhibitors offer the lowest bleeding risk without increasing ischemic events. This combination is recommended over other antithrombotic strategies for improved safety in AF patients with PCI.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI) require antithrombotic therapy, typically oral anticoagulants and antiplatelets.
- Optimal antithrombotic combination strategies for AF patients undergoing PCI remain unclear, necessitating comparative safety and efficacy research.
- Current guidelines recommend antithrombotic therapy but lack definitive guidance on the best combination for this high-risk population.
Purpose of the Study:
- To investigate and compare the efficacy and safety of various antithrombotic strategies in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).
- To identify the optimal antithrombotic regimen balancing bleeding risk and prevention of major adverse cardiovascular events.
- To evaluate combinations involving vitamin K antagonists (VKA) and direct oral anticoagulants (DOACs) with dual antiplatelet therapy (DAPT) or P2Y12 inhibitors.
Main Methods:
- A systematic search of randomized trials was conducted in PubMed and EMBASE up to September 2019.
- Five eligible trials involving 11,532 patients were analyzed, comparing nine different antithrombotic strategies.
- Primary outcomes assessed were trial-defined bleeding events (safety) and major adverse cardiovascular events (efficacy).
Main Results:
- Vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT) significantly increased bleeding risk compared to most other combinations.
- Apixaban combined with a P2Y12 inhibitor demonstrated the lowest bleeding risk among all evaluated strategies.
- No significant differences in major adverse cardiovascular events (ischemic outcomes) were observed between the various antithrombotic regimens.
Conclusions:
- In patients with atrial fibrillation (AF) undergoing PCI, apixaban plus P2Y12 inhibitors represent the safest antithrombotic strategy, associated with the lowest bleeding risk.
- This combination (apixaban + P2Y12 inhibitor) did not compromise efficacy, showing no increase in ischemic outcomes compared to other regimens.
- The findings suggest that apixaban-based regimens should be strongly considered for AF patients undergoing PCI to minimize bleeding complications.
Abstract:
For patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI), antithrombotic therapy including oral anticoagulants and antiplatelets are indicated. The optimal combination is not known. We investigated the efficacy and safety of different antithrombotic strategies in patients with AF undergoing PCI. PUBMED and EMBASE were searched through September 2019 for randomized trials investigating the efficacy and safety of different antithrombotic strategies in patients with AF who underwent PCI and/or acute coronary syndrome. Nine antithrombotic strategies were compared including combinations of vitamin K antagonist (VKA) with dual antiplatelet therapy (DAPT) or P2Y12 inhibitor, combinations of direct oral anticoagulants (DOAC) (apixaban, dabigatran, rivaroxaban, and edoxaban) with DAPT or P2Y12 inhibitor (clopidogrel, prasugrel, and ticagrelor). The primary safety outcome was trial defined primary bleeding outcome. The primary efficacy outcome was trial defined major adverse cardiovascular events. Our search identified 5 eligible trials that enrolled a total of 11,532 patients and compared 9 treatment strategies. VKA + DAPT significantly increased bleeding when compared with most combinations (for example, vs VKA + P2Y12 inhibitor: odds ratio 2.11; 95% confidence interval [1.76 to 2.52], p <0.001). Of all the combinations, apixaban + P2Y12 inhibitor showed the lowest bleeding risk (for example, vs VKA + P2Y12 inhibitor: odds ratio 0.63; 95% confidence interval [0.51 to 0.78], p <0.001) and was ranked the best treatment. There were no significant differences in ischemic outcome of major adverse cardiovascular events between various antithrombotic regimens. In conclusion, in patients with AF undergoing PCI, apixaban + P2Y12 inhibitors were associated with lowest bleeding compared with other regimens including other DOACs + P2Y12 inhibitors with no increase in ischemic outcomes.
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