Dual versus triple therapy in patients on oral anticoagulants and undergoing coronary stent implantation: A systematic review and meta-analysis

Federico Fortuni, Marco Ferlini, Sergio Leonardi, Filippo Angelini, Gabriele Crimi, Alberto Somaschini, Stefano Cornara, Antonella Potenza, Stefano De Servi, Luigi Oltrona Visconti, Gaetano Maria De Ferrari

Research output: Contribution to journalArticle

Abstract

Background and aims: There is contrasting evidence regarding the optimal antithrombotic regimen after percutaneous coronary stent implantation in patients on oral anticoagulants. A systematic review and meta-analysis was performed to explore the comparative efficacy and safety of dual (an antiplatelet plus an oral anticoagulant) versus triple therapy (dual antiplatelet therapy plus an oral anticoagulant). Methods: We searched the literature for randomized controlled trials (RCTs) or observational studies (OSs) addressing this issue. The efficacy outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction and stent thrombosis. The safety outcomes were major bleeding events and all bleeding events. The analyses were stratified by type of anticoagulant and of antiplatelet used in dual therapy. Results: Four RCTs and ten OSs met our inclusion criteria including a total of 10,126 patients. 5671 patients received triple therapy whereas 4455 received dual therapy. Median follow up was 12 months. There was no difference between dual therapy and triple therapy regarding efficacy outcomes. Dual therapy significantly reduced the risk of major bleeding (RR 0.66; CI 95% 0.52–0.83; P = 0.0005) and of all bleeding events (RR 0.67, CI 95% 0.55–0.80; P < 0.0001). The effect was consistent regardless of the type of antiplatelet and anticoagulant used in dual therapy. Conclusion: Dual antithrombotic therapy after coronary stenting in anticoagulated patients significantly reduces bleeding events compared with triple therapy. Dual therapy might be considered in this setting especially when bleeding risk outweighs ischemic risk, although our study was not sufficiently powered to detect a difference in ischemic endpoints.

Original languageEnglish
JournalInternational Journal of Cardiology
DOIs
Publication statusAccepted/In press - Jan 1 2018

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Anticoagulants
Stents
Meta-Analysis
Hemorrhage
Therapeutics
Observational Studies
Randomized Controlled Trials
Safety
Mortality
Thrombosis
Myocardial Infarction

Keywords

  • Antithrombotic regimen after PCI
  • Dual antiplatelet therapy
  • Oral anticoagulants

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

@article{6f8dfd66052d4c07b6b9a5cd48223248,
title = "Dual versus triple therapy in patients on oral anticoagulants and undergoing coronary stent implantation: A systematic review and meta-analysis",
abstract = "Background and aims: There is contrasting evidence regarding the optimal antithrombotic regimen after percutaneous coronary stent implantation in patients on oral anticoagulants. A systematic review and meta-analysis was performed to explore the comparative efficacy and safety of dual (an antiplatelet plus an oral anticoagulant) versus triple therapy (dual antiplatelet therapy plus an oral anticoagulant). Methods: We searched the literature for randomized controlled trials (RCTs) or observational studies (OSs) addressing this issue. The efficacy outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction and stent thrombosis. The safety outcomes were major bleeding events and all bleeding events. The analyses were stratified by type of anticoagulant and of antiplatelet used in dual therapy. Results: Four RCTs and ten OSs met our inclusion criteria including a total of 10,126 patients. 5671 patients received triple therapy whereas 4455 received dual therapy. Median follow up was 12 months. There was no difference between dual therapy and triple therapy regarding efficacy outcomes. Dual therapy significantly reduced the risk of major bleeding (RR 0.66; CI 95{\%} 0.52–0.83; P = 0.0005) and of all bleeding events (RR 0.67, CI 95{\%} 0.55–0.80; P < 0.0001). The effect was consistent regardless of the type of antiplatelet and anticoagulant used in dual therapy. Conclusion: Dual antithrombotic therapy after coronary stenting in anticoagulated patients significantly reduces bleeding events compared with triple therapy. Dual therapy might be considered in this setting especially when bleeding risk outweighs ischemic risk, although our study was not sufficiently powered to detect a difference in ischemic endpoints.",
keywords = "Antithrombotic regimen after PCI, Dual antiplatelet therapy, Oral anticoagulants",
author = "Federico Fortuni and Marco Ferlini and Sergio Leonardi and Filippo Angelini and Gabriele Crimi and Alberto Somaschini and Stefano Cornara and Antonella Potenza and {De Servi}, Stefano and {Oltrona Visconti}, Luigi and {De Ferrari}, {Gaetano Maria}",
year = "2018",
month = "1",
day = "1",
doi = "10.1016/j.ijcard.2018.08.019",
language = "English",
journal = "International Journal of Cardiology",
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}

TY - JOUR

T1 - Dual versus triple therapy in patients on oral anticoagulants and undergoing coronary stent implantation

T2 - A systematic review and meta-analysis

AU - Fortuni, Federico

AU - Ferlini, Marco

AU - Leonardi, Sergio

AU - Angelini, Filippo

AU - Crimi, Gabriele

AU - Somaschini, Alberto

AU - Cornara, Stefano

AU - Potenza, Antonella

AU - De Servi, Stefano

AU - Oltrona Visconti, Luigi

AU - De Ferrari, Gaetano Maria

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background and aims: There is contrasting evidence regarding the optimal antithrombotic regimen after percutaneous coronary stent implantation in patients on oral anticoagulants. A systematic review and meta-analysis was performed to explore the comparative efficacy and safety of dual (an antiplatelet plus an oral anticoagulant) versus triple therapy (dual antiplatelet therapy plus an oral anticoagulant). Methods: We searched the literature for randomized controlled trials (RCTs) or observational studies (OSs) addressing this issue. The efficacy outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction and stent thrombosis. The safety outcomes were major bleeding events and all bleeding events. The analyses were stratified by type of anticoagulant and of antiplatelet used in dual therapy. Results: Four RCTs and ten OSs met our inclusion criteria including a total of 10,126 patients. 5671 patients received triple therapy whereas 4455 received dual therapy. Median follow up was 12 months. There was no difference between dual therapy and triple therapy regarding efficacy outcomes. Dual therapy significantly reduced the risk of major bleeding (RR 0.66; CI 95% 0.52–0.83; P = 0.0005) and of all bleeding events (RR 0.67, CI 95% 0.55–0.80; P < 0.0001). The effect was consistent regardless of the type of antiplatelet and anticoagulant used in dual therapy. Conclusion: Dual antithrombotic therapy after coronary stenting in anticoagulated patients significantly reduces bleeding events compared with triple therapy. Dual therapy might be considered in this setting especially when bleeding risk outweighs ischemic risk, although our study was not sufficiently powered to detect a difference in ischemic endpoints.

AB - Background and aims: There is contrasting evidence regarding the optimal antithrombotic regimen after percutaneous coronary stent implantation in patients on oral anticoagulants. A systematic review and meta-analysis was performed to explore the comparative efficacy and safety of dual (an antiplatelet plus an oral anticoagulant) versus triple therapy (dual antiplatelet therapy plus an oral anticoagulant). Methods: We searched the literature for randomized controlled trials (RCTs) or observational studies (OSs) addressing this issue. The efficacy outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction and stent thrombosis. The safety outcomes were major bleeding events and all bleeding events. The analyses were stratified by type of anticoagulant and of antiplatelet used in dual therapy. Results: Four RCTs and ten OSs met our inclusion criteria including a total of 10,126 patients. 5671 patients received triple therapy whereas 4455 received dual therapy. Median follow up was 12 months. There was no difference between dual therapy and triple therapy regarding efficacy outcomes. Dual therapy significantly reduced the risk of major bleeding (RR 0.66; CI 95% 0.52–0.83; P = 0.0005) and of all bleeding events (RR 0.67, CI 95% 0.55–0.80; P < 0.0001). The effect was consistent regardless of the type of antiplatelet and anticoagulant used in dual therapy. Conclusion: Dual antithrombotic therapy after coronary stenting in anticoagulated patients significantly reduces bleeding events compared with triple therapy. Dual therapy might be considered in this setting especially when bleeding risk outweighs ischemic risk, although our study was not sufficiently powered to detect a difference in ischemic endpoints.

KW - Antithrombotic regimen after PCI

KW - Dual antiplatelet therapy

KW - Oral anticoagulants

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U2 - 10.1016/j.ijcard.2018.08.019

DO - 10.1016/j.ijcard.2018.08.019

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JF - International Journal of Cardiology

SN - 0167-5273

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