Antithrombotic Monotherapy or Combination Therapy for Atrial Fibrillation in Stable Coronary Artery Disease: A...

In patients with atrial fibrillation and stable coronary artery disease, guidelines recommend oral anticoagulation monotherapy after periods on dual antithrombotic therapy. These recommendations are based on evidence from prematurely terminated randomized controlled trials that were underpowered for bleeding and mortality end points. New data are available, so we conducted a systematic review and meta-analysis to pool the totality of randomized evidence.

This investigation was preregistered on International Prospective Register of Systematic Reviews (CRD42024590457). Systematic searches and data extraction were performed independently and in duplicate for randomized controlled trials enrolling patients with atrial fibrillation and stable coronary artery disease that reported clinical end points. The prespecified coprimary end points were major bleeding and all-cause death. Prespecified secondary outcomes included all bleeding, cardiovascular death, noncardiovascular death, myocardial infarction, stroke, the composite of net adverse cardiovascular events and coronary revascularization. End point data were pooled using fixed and random effect models, to generate hazard ratios (HR) and relative risks and corresponding 95% CIs.

Four randomized controlled trials enrolling 4092 patients were eligible, with 2049 randomized to monotherapy and 2043 randomized to dual therapy. Monotherapy reduced the hazard of major bleeding by 41% (HR, 0.59 [95% CI, 0.44-0.79], P<0.001, I²=29%). There was no statistically significant difference in hazard of all-cause death (HR, 0.89 [95% CI, 0.45-1.74], P=0.73, I²=72%), or other secondary outcomes.

In patients with stable coronary artery disease and atrial fibrillation, oral anticoagulation monotherapy reduces major bleeding compared with dual antithrombotic therapy. There were no significant differences in all-cause and cardiovascular death, myocardial infarction, stroke, adverse cardiovascular events, and coronary revascularization.