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Direct oral anticoagulant-antiplatelet regimen effective in STEMI, not other ACS
Clinical benefits of direct oral anticoagulants in addition to antiplatelet therapy as a secondary prevention after ACS may be dependent on type of ACS, according to results published in JAMA Cardiology.
The regimen appears to be beneficial in patients with STEMI but not in patients with non-ST segment elevation ACS, researchers reported.
“During the last few decades, several antithrombotic drugs have been developed and implemented in treating ACS, contributing to an important reduction in the risk of mortality and recurrent ischemic events,” Mauro Chiarito, MD, from the department of biomedical sciences at Humanitas University in Milan, and colleagues wrote. “Increasing antithrombotic efficacy has been shown to reduce the risk of ischemic events; however, it is at the cost of a parallel increase in the risk of bleeding.”
To assess the safety and efficacy of direct oral anticoagulants in addition to antiplatelet therapy after ACS, the researchers evaluated 29,667 patients from six randomized trials.
Chiarito and colleagues used PRISMA guidelines to abstract data and assess quality and validity and pooled data using random-effects models.
The primary endpoint was a composite of CV death, MI and stroke, and the key safety endpoint was major bleeding, according to the study.
Patients included in the studies who presented with ACS (49.1% with STEMI) were randomly assigned to direct oral anticoagulants or a placebo in addition to antiplatelet therapy.
Patients who were treated with direct oral anticoagulants had a significantly lower risk for the composite of CV death, MI and stroke vs. those who received antiplatelet therapy alone (OR = 0.85; 95% CI, 0.77-0.93).
This benefit was significant among patients with STEMI (OR = 0.76; 95% CI, 0.66-0.88); however, the researchers found no significant treatment effect in patients with non-STEACS (OR = 0.92; 95% CI, 0.78 1.09).
With respect to safety, direct oral anticoagulants plus antiplatelet therapy were associated with a higher risk for major bleeding vs. antiplatelet therapy alone (OR = 3.17; 95% CI, 2.27-4.42). These results were consistent in patients with STEMI (OR = 3.45; 95% CI, 1.95-6.09) and non-STEACS (OR = 2.19; 95% CI, 1.38-3.48).
“The risk-benefit profile of direct oral anticoagulants in addition to [antiplatelet therapy] appears to differ by ACS type,” the researchers wrote. “Direct oral anticoagulants might represent an attractive strategy in patients with ST-segment elevation myocardial infarction.” – by Dave Quaile
Disclosures: Chiarito reports no relevant financial disclosures. Please see the study for a list of the other authors’ relevant financial disclosures.