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Dual vs triple antithrombotic therapy in atrial fibrillation and acute coronary syndrome: An updated meta-analysis of
Enkhtsogt Sainbayar1, Hoang Nhat Pham1, April Olson1
1Department of Medicine, UA College of Medicine, University of Arizona Tucson, Tucson, AZ, USA.
Insights
Dual antithrombotic therapy (DAT) in atrial fibrillation (AF) and acute coronary syndrome (ACS) patients shows reduced bleeding risk compared to triple antithrombotic therapy (TAT). No significant differences were observed in major adverse cardiac events, myocardial infarction, or stroke.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Managing antithrombotic treatment in patients with both atrial fibrillation (AF) and acute coronary syndrome (ACS) presents a clinical challenge.
- Comparing dual antithrombotic therapy (DAT) with triple antithrombotic therapy (TAT) is crucial for optimizing patient outcomes.
Purpose of the Study:
- To compare the efficacy and safety of dual antithrombotic therapy (DAT) versus triple antithrombotic therapy (TAT) in patients with AF and ACS.
- To evaluate outcomes including major adverse cardiac events (MACE), bleeding, stroke, stent thrombosis, and myocardial infarction (MI).
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) comparing DAT (DOACs/warfarin + antiplatelets) with TAT (DOACs/warfarin, aspirin, P2Y12 inhibitor).
- Searched multiple databases from inception to December 17, 2023.
- Analyzed outcomes using a random-effects model, estimating relative risks and 95% confidence intervals.
Main Results:
- Ten RCTs involving 6186 patients on TAT and 6800 patients on DAT were included.
- DAT was associated with significantly lower rates of bleeding events compared to TAT across 3, 6, and 12-month durations (RR 0.69, 0.65, 0.62 respectively).
- No significant differences were found between DAT and TAT for MACE, MI, stroke, or stent thrombosis.
Conclusions:
- Dual antithrombotic therapy (DAT) is associated with a reduced risk of bleeding in patients with atrial fibrillation and acute coronary syndrome compared to triple antithrombotic therapy (TAT).
- DAT offers a favorable safety profile without compromising efficacy regarding major adverse cardiac events, myocardial infarction, or stroke.
Abstract:
Antithrombotic treatment in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) poses a dilemma. We compared outcomes of dual antithrombotic therapy (DAT) (direct oral anticoagulants (DOACs)/warfarin + antiplatelets) vs triple antithrombotic therapy (TAT) (DOACs/warfarin, aspirin, and P2Y12 inhibitor) in this population. Multiple databases were searched from inception to December 17, 2023 to identify randomized controlled trials (RCTs) comparing DAT vs TAT in patients with AF and ACS. Outcomes included major adverse cardiac events (MACE), bleeding events, stroke, stent thrombosis, and myocardial infarction (MI). Relative risk and 95% confidence intervals were estimated with a random-effects model using the inverse-variance technique. We assigned I2 > 50% as an indicator of statistical heterogeneity. p-Value <0.05 was considered significant. Ten RCTs comprising 6186 patients on TAT (female 26%, mean age 71 ± 9 years) and 6800 patients on DAT (female 27%, mean age 71 ± 9 years) were included. Patients receiving DAT experienced lower rates of bleeding events compared to those receiving TAT, with relative risks of 0.69 [0.55-0.87] (p < 0.001), 0.65 [0.40-1.06] (p = 0.09), and 0.62 [0.46-0.84] (p < 0.001) for TAT durations of 3, 6, and 12 months, respectively. No difference was seen in the occurrence of MACE, MI, stroke, or stent thrombosis between DAT and TAT across all three durations of TAT. This is the largest pooled analysis comparing TAT to DAT stratified by the duration of antithrombotic therapy. Our results revealed that DAT was associated with reduced bleeding risk despite no difference in other outcomes.
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