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Antiplatelet therapy in patients with chronic coronary syndrome requiring oral anticoagulation: An updated
Fernando Garagoli1, Walter Masson1, Martin Lobo2
1Cardiology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
Insights
For patients with chronic coronary syndrome needing anticoagulation, adding antiplatelet therapy increases bleeding and cardiovascular death risks without reducing overall mortality or ischemic events compared to anticoagulation alone.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Patients with chronic coronary syndrome (CCS) often require long-term oral anticoagulation (OAC), frequently for atrial fibrillation (AF).
- Optimal antithrombotic strategies in CCS patients on OAC are not well-established.
- This meta-analysis evaluates OAC plus single antiplatelet therapy (SAPT) versus OAC monotherapy.
Purpose of the Study:
- To compare the efficacy and safety of dual antithrombotic therapy (OAC + SAPT) versus OAC monotherapy in patients with CCS.
- To determine the impact on all-cause death, cardiovascular death, and ischemic events.
- To assess the safety profile, particularly bleeding risk.
Main Methods:
- Systematic literature search of multiple databases up to November 12, 2025.
- Inclusion of six randomized trials with 5,924 participants.
- Primary endpoint: all-cause death; Secondary endpoints: cardiovascular death, myocardial infarction, ischemic stroke, systemic embolism; Safety endpoint: major and clinically relevant non-major bleeding (ISTH definition).
Main Results:
- Dual therapy (OAC + SAPT) did not significantly reduce all-cause death (OR 1.31; 95% CI 0.89-1.92).
- Dual therapy increased cardiovascular death risk (OR 1.42; 95% CI 1.05-1.92) but showed similar rates for myocardial infarction, ischemic stroke, and systemic embolism compared to OAC monotherapy.
- Dual therapy significantly elevated the risk of major bleeding (OR 2.20; 95% CI 1.51-3.22) and major or clinically relevant non-major bleeding (OR 2.30; 95% CI 1.72-3.06).
Conclusions:
- Dual therapy (OAC + SAPT) in CCS patients requiring OAC does not improve survival or reduce ischemic events compared to OAC alone.
- Dual therapy significantly increases the risk of major bleeding and cardiovascular death.
- OAC monotherapy appears to be a safer strategy regarding bleeding risk in this patient population.
Background:
Patients with chronic coronary syndrome (CCS) often require long-term oral anticoagulation (OAC), most commonly for atrial fibrillation (AF). Evidence on the optimal antithrombotic strategy in this setting remains inconclusive, prompting this updated meta-analysis of randomized trials comparing OAC plus a single antiplatelet therapy (SAPT) with OAC monotherapy.
Methods:
We systematically searched PubMed/MEDLINE, SciELO, Latindex, LILACS, the Cochrane Library, and ClinicalTrials.gov up to November 12, 2025. The primary efficacy endpoint was all-cause death, while secondary efficacy endpoints included cardiovascular death, acute myocardial infarction, ischemic stroke, and systemic embolism, each analyzed individually. Safety endpoints comprised major and clinically relevant non-major bleeding (International Society on Thrombosis and Hemostasis [ISTH] definition).
Results:
Six randomized trials including 5,924 participants were analyzed. All-cause death did not differ significantly between OAC plus SAPT and OAC monotherapy (OR 1.31; 95 % CI 0.89-1.92). Dual therapy was associated with an increased risk of cardiovascular death (OR 1.42; 95 % CI 1.05-1.92), whereas rates of myocardial infarction (OR 0.98; 95 % CI 0.60-1.57), ischemic stroke (OR 0.95; 95 % CI 0.64-1.39), and systemic embolism (OR 1.00; 95 % CI 0.20-4.95) were similar between groups. Safety outcomes were markedly worse with dual therapy, which significantly increased the risk of major bleeding (OR 2.20; 95 % CI 1.51-3.22) and major or clinically relevant non-major bleeding (OR 2.30; 95 % CI 1.72-3.06).
Conclusions:
In patients with CCS requiring long-term OAC, dual therapy (OAC plus SAPT) did not reduce all-cause death nor ischemic events compared with OAC alone but significantly increased major bleeding and cardiovascular death. PROSPERO Registration No.: CRD420251239917.
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