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The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Optimal Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention:
Renato D Lopes1, Hwanhee Hong2,3, Ralf E Harskamp4
1Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
Insights
For atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI), avoiding aspirin in antithrombotic therapy reduces bleeding risk without impacting effectiveness. Non-vitamin K antagonist oral anticoagulant (NOAC) plus P2Y12 inhibitor is the preferred regimen.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Antithrombotic therapy is crucial for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).
- Balancing antithrombotic treatment to minimize bleeding and ischemic risks is a significant clinical challenge.
- Optimizing antithrombotic strategies is essential for improving outcomes in this high-risk patient population.
Purpose of the Study:
- To conduct an up-to-date network meta-analysis evaluating the safety and efficacy of four antithrombotic regimens.
- To identify the optimal antithrombotic treatment strategy for patients with AF undergoing PCI.
Main Methods:
- A systematic network meta-analysis was performed using data from five randomized controlled trials (N=11,542).
- Bayesian random-effects models were applied following PRISMA guidelines.
- Primary outcomes included Thrombolysis In Myocardial Infarction (TIMI) major bleeding and major adverse cardiovascular events (MACE).
Main Results:
- Regimens discontinuing aspirin showed a significantly lower risk of TIMI major bleeding compared to vitamin K antagonists (VKA) plus dual antiplatelet therapy (DAPT).
- Odds ratios for major bleeding were 0.57 (VKA + P2Y12 inhibitor), 0.69 (non-VKA oral anticoagulant [NOAC] + DAPT), and 0.52 (NOAC + P2Y12 inhibitor).
- No significant differences in major adverse cardiovascular events (MACE) were observed across the evaluated regimens.
Conclusions:
- Antithrombotic regimens including VKA plus DAPT should generally be avoided in patients with AF undergoing PCI.
- Discontinuing aspirin may reduce bleeding risk without compromising antithrombotic effectiveness.
- A NOAC plus a P2Y12 inhibitor, without aspirin, appears to be the most favorable and preferred treatment option for most patients.
Importance:
Antithrombotic treatment in patients with atrial fibrillation (AF) and percutaneous coronary intervention (PCI) presents a balancing act with regard to bleeding and ischemic risks.
Objectives:
To evaluate the safety and efficacy of 4 antithrombotic regimens by conducting an up-to-date network meta-analysis and to identify the optimal treatment for patients with AF undergoing PCI.
Data Sources:
Online computerized database (MEDLINE).
Study Selection:
Five randomized studies were included (N = 11 542; WOEST, PIONEER AF-PCI, RE-DUAL PCI, AUGUSTUS, ENTRUST-AF PCI).
Data Extraction And Synthesis:
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in this network meta-analysis, in which bayesian random-effects models were applied. The data were analyzed from September 9 to 29, 2019.
Main Outcomes And Measures:
The primary safety outcome was thrombolysis in myocardial infarction (TIMI) major bleeding and the primary efficacy outcome was trial-defined major adverse cardiovascular events (MACE).
Results:
The total number of participants included in the study was 11 532. The mean age of the participants ranged from 70 to 72 years, 69% to 83% were male, 20% to 26% were female, and the participants were predominantly white (>90%). Compared with vitamin K antagonists (VKA) plus dual antiplatelet therapy (DAPT) (reference), the odds ratios (ORs) (95% credible intervals) for TIMI major bleeding were 0.57 (0.31-1.00) for VKA plus P2Y12 inhibitor, 0.69 (0.40-1.16) for non-VKA oral anticoagulant (NOAC) plus DAPT, and 0.52 (0.35-0.79) for NOAC plus P2Y12 inhibitor. For MACE, using VKA plus DAPT as reference, the ORs (95% credible intervals) were 0.97 (0.64-1.42) for VKA plus P2Y12 inhibitor, 0.95 (0.64-1.39) for NOAC plus DAPT, and 1.03 (0.77-1.38) for NOAC plus P2Y12 inhibitor.
Conclusions And Relevance:
The findings of this study suggest that an antithrombotic regimen of VKA plus DAPT should generally be avoided, because regimens in which aspirin is discontinued may lead to lower bleeding risk and no difference in antithrombotic effectiveness. The use of a NOAC plus a P2Y12 inhibitor without aspirin may be the most favorable treatment option and the preferred antithrombotic regimen for most patients with AF undergoing PCI.
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