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Network meta-analysis and trial sequential analysis for atrial fibrillation patients receiving PCI or with ACS

Shu-Mei Yang1, Chi-Jung Huang1, Chen-Huan Chen2,3,4,5

  • 1Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.

Journal of the Chinese Medical Association : JCMA
|November 11, 2021
PubMed

Insights

Novel oral anticoagulants plus a P2Y12 inhibitor reduce bleeding risk in atrial fibrillation (AF) patients post-PCI or with ACS. However, this strategy shows a numerically higher risk of stent thrombosis and myocardial infarction, suggesting triple therapy remains an option.

Area of Science:

  • Cardiology
  • Pharmacology
  • Clinical Trials

Background:

  • Antithrombotic treatment selection is complex for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) or with acute coronary syndrome (ACS).
  • Optimizing antithrombotic therapy balances efficacy and safety in this high-risk population.

Purpose of the Study:

  • To compare the efficacy and safety of different antithrombotic strategies in patients with AF following PCI or ACS.
  • To evaluate novel oral anticoagulants (NOACs) combined with P2Y12 inhibitors against traditional therapies.

Main Methods:

  • A systematic review and network meta-analysis of randomized controlled trials were conducted.
  • Five studies involving 11,532 patients were analyzed.
  • Trial sequential analysis (TSA) assessed the reliability of findings regarding dual versus triple antithrombotic therapy.

Main Results:

  • Novel oral anticoagulant (NOAC) + P2Y12 inhibitor demonstrated a significantly better primary safety outcome compared to vitamin K antagonist + dual antiplatelet therapy (OR: 0.53; 95% CI, 0.31-0.90).
  • This NOAC combination showed the lowest probability of major bleeding and intracranial hemorrhage.
  • In patients not on aspirin, TSA indicated conclusive evidence for reduced safety outcomes but inconclusive evidence for increased stent thrombosis and myocardial infarction risks.

Conclusions:

  • NOAC + P2Y12 inhibitor offers the lowest bleeding risk for AF patients undergoing PCI or with ACS.
  • A statistically nonsignificant, numerically higher risk of stent thrombosis and myocardial infarction was observed with this strategy.
  • Triple antithrombotic therapy should remain a consideration for patients at high risk of stent thrombosis or myocardial infarction.
Abstract

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