Benefit of dual antithrombotic therapy with direct oral anticoagulants in patients with atrial fibrillation undergoing percutaneous coronary intervention: a systematic review and metaanalysis of randomized clinical trials

Antithrombotic treatment in patients with atrial fibrillation undergoing percutaneous coronary intervention is still debated. We conducted a meta-analysis of recent randomized controlled trials to evaluate the benefit of different antithrombotic strategies. Data were analyzed between May and September 2019. Efficacy outcomes were trial-defined major adverse cardiovascular events (MACE); its individual components; stent thrombosis. Safety outcomes were trial-defined primary bleeding outcome; TIMI and ISTH major bleeding; clinically relevant non-major bleeding; intracranial hemorrhage. Differences in outcomes among groups were expressed as pooled odds ratio (OR) and corresponding 95% confidence interval (CI). Four randomized studies were included (10,969 patients). The mean age ranged from 69 to 72 years, prevalence of acute coronary syndrome (ACS) varied from 48 to 62%. Comparing dual antithrombotic therapy (DAT) with a direct oral anticoagulant (DOAC) versus triple antithrombotic therapy (TAT) with vitamin K antagonist (VKA), OR for trial-defined MACE and primary bleeding outcome were 1.03 (95% CI, 0.86-1.24) and 0.59 (95% CI, 0.41-0.86), respectively. There was a 68% lower risk of intracranial hemorrhage and a non-statistically significant higher risk of stent thrombosis with DAT. DAT was as effective and safer than TAT in patients with stable coronary artery disease, while a trend towards increased ischemic events was seen in ACS patients. DAT with a DOAC showed similar efficacy and less bleeding than TAT with a VKA. However, increased stent thrombosis with DAT may be present, and TAT should be considered in patients at high ischemic risk, such as ACS patients.