Oral anticoagulant monotherapy in patients with chronic coronary disease: An updated meta-analysis

The optimal antithrombotic strategy for patients with chronic coronary disease requiring long-term anticoagulation remains uncertain. While dual therapy with oral anticoagulants (OACs) and antiplatelet agents is common, it significantly increases bleeding risk. This meta-analysis was conducted to compare the efficacy and safety of OAC monotherapy against combination therapy.

We searched PubMed, Embase, ClinicalTrials.gov, and Cochrane library through August 2025 to identify randomized controlled trials (RCTs) comparing OAC monotherapy to dual therapy (OAC plus a single antiplatelet agent) in patients with chronic coronary disease. The primary outcome was a composite of cardiovascular death, stroke, myocardial infarction, and major bleeding.

Five RCTs with 4964 participants were included. OAC monotherapy was associated with a significantly lower risk of the primary composite outcome (RR: 0.68, 95 % CI: 0.53-0.85). The risks of all-cause death, cardiovascular death, myocardial infarction, stroke, and systemic embolism were comparable between the two groups. OAC monotherapy significantly reduced the risk of major bleeding (RR: 0.49, 95 % CI: 0.31-0.77) and major or clinically relevant non-major bleeding (RR: 0.50, 95 % CI: 0.37-0.68).

In patients with chronic coronary disease requiring long-term anticoagulation, OAC monotherapy reduces bleeding complications without increasing the risk of ischemic events compared to dual therapy. These findings support the use of a simplified antithrombotic strategy without antiplatelet therapy in this patient population.