TY - JOUR
T1 - Antithrombotic strategies in patients needing oral anticoagulation undergoing percutaneous coronary intervention
T2 - A network meta-analysis
AU - Saglietto, Andrea
AU - D'Ascenzo, Fabrizio
AU - Errigo, Daniele
AU - Leonardi, Sergio
AU - Dewilde, Willem J.
AU - Conrotto, Federico
AU - Omedè, Pierluigi
AU - Montefusco, Antonio
AU - Angelini, Filippo
AU - De Filippo, Ovidio
AU - Bianco, Matteo
AU - Gallone, Guglielmo
AU - Bruno, Francesco
AU - Zaccaro, Lorenzo
AU - Giannini, Francesco
AU - Latib, Azeem
AU - Colombo, Antonio
AU - Costa, Francesco
AU - De Ferrari, Gaetano Maria
N1 - Publisher Copyright:
© 2020 Wiley Periodicals LLC
PY - 2021/3
Y1 - 2021/3
N2 - Background: The optimal antithrombotic regimen in patients with a concomitant indication for oral anticoagulation (OAT) presenting with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) remains unclear. Objectives: To perform a network meta-analysis of all randomized controlled trials (RCTs) evaluating different antithrombotic regimens among patients with ACS or undergoing PCI requiring OAT. Methods: Network meta-analysis was performed in a frequentist framework. Antithrombotic regimens were categorized by OAC type (vitamin K antagonist-based [VKA]; non-VKA OAT [NOAC]) and antiplatelet agents (P2Y inhibitor only: dual therapy [DAT]; P2Y plus aspirin: triple therapy [TAT]). Safety outcomes were Thrombolysis in Myocardial Infarction (TIMI) major bleeding and intracranial hemorrhage (ICH). Efficacy outcomes were cardiovascular death, myocardial infarction, stroke and stent-thrombosis (ST). Results: Five RCTs were included, encompassing 10,797 patients (atrial fibrillation 69–100%, ACS 28–62%, PCI 77–100%). Both VKA and NOAC-based DAT regimens reduced the occurrence of TIMI major bleeding compared to VKA TAT (VKA DAT: RR 0.62, 95% CI 0.39–0.98; NOAC DAT: RR 0.52, 95% CI 0.39–0.70). Nevertheless, only NOAC DAT significantly reduced the occurrence of ICH compared to VKA TAT (RR 0.33, 95% CI 0.17–0.64). Ischemic outcomes were similar among the four treatment regimens. However, numerical, potentially clinically important, higher ST occurrence was observed for NOAC DAT as compared to both VKA TAT (1.50, 95% confidence interval [CI] 0.96–2.33) and NOAC TAT (1.86, 95% CI 0.93–3.73). Conclusion: DAT regimens present the highest safety profile among antithrombotic strategies, with a NOAC-specific impact on ICH reduction. NOAC DAT might entail clinically important higher ST occurrence, warranting a case-by-case comprehensive evaluation that integrates patient- and procedure-related residual ischemic risk with the patient-specific bleeding risk.
AB - Background: The optimal antithrombotic regimen in patients with a concomitant indication for oral anticoagulation (OAT) presenting with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) remains unclear. Objectives: To perform a network meta-analysis of all randomized controlled trials (RCTs) evaluating different antithrombotic regimens among patients with ACS or undergoing PCI requiring OAT. Methods: Network meta-analysis was performed in a frequentist framework. Antithrombotic regimens were categorized by OAC type (vitamin K antagonist-based [VKA]; non-VKA OAT [NOAC]) and antiplatelet agents (P2Y inhibitor only: dual therapy [DAT]; P2Y plus aspirin: triple therapy [TAT]). Safety outcomes were Thrombolysis in Myocardial Infarction (TIMI) major bleeding and intracranial hemorrhage (ICH). Efficacy outcomes were cardiovascular death, myocardial infarction, stroke and stent-thrombosis (ST). Results: Five RCTs were included, encompassing 10,797 patients (atrial fibrillation 69–100%, ACS 28–62%, PCI 77–100%). Both VKA and NOAC-based DAT regimens reduced the occurrence of TIMI major bleeding compared to VKA TAT (VKA DAT: RR 0.62, 95% CI 0.39–0.98; NOAC DAT: RR 0.52, 95% CI 0.39–0.70). Nevertheless, only NOAC DAT significantly reduced the occurrence of ICH compared to VKA TAT (RR 0.33, 95% CI 0.17–0.64). Ischemic outcomes were similar among the four treatment regimens. However, numerical, potentially clinically important, higher ST occurrence was observed for NOAC DAT as compared to both VKA TAT (1.50, 95% confidence interval [CI] 0.96–2.33) and NOAC TAT (1.86, 95% CI 0.93–3.73). Conclusion: DAT regimens present the highest safety profile among antithrombotic strategies, with a NOAC-specific impact on ICH reduction. NOAC DAT might entail clinically important higher ST occurrence, warranting a case-by-case comprehensive evaluation that integrates patient- and procedure-related residual ischemic risk with the patient-specific bleeding risk.
KW - acute coronary syndromes
KW - atrial fibrillation
KW - dual antithrombotic therapy
KW - novel oral anticoagulants
KW - percutaneous coronary intervention
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U2 - 10.1002/ccd.29192
DO - 10.1002/ccd.29192
M3 - Article
C2 - 32790145
AN - SCOPUS:85089388978
SN - 1522-1946
VL - 97
SP - 581
EP - 588
JO - Catheterization and Cardiovascular Interventions
JF - Catheterization and Cardiovascular Interventions
IS - 4
ER -