This article is more than 5 years old. Information may no longer be current.
Dual antithrombotic therapy safer than triple therapy in AF after PCI
Click Here to Manage Email Alerts
Among patients with atrial fibrillation who underwent PCI, dual antithrombotic therapy was associated with significantly lower bleeding compared with triple therapy, with similar thrombotic outcomes, according to a new meta-analysis.
According to the study background, many patients with AF are treated with an oral anticoagulant for stroke prevention, and when they undergo PCI with stenting, they are often prescribed a P2Y12 inhibitor plus aspirin to prevent stent thrombosis. However, there is little evidence to support this so-called triple therapy, and it has been associated with bleeding risk, the researchers wrote.
Harsh B. Golwala, MD, advanced interventional cardiology fellow at Brigham and Women’s Hospital Heart & Vascular Center at Harvard Medical School, and colleagues conducted a systematic review and meta-analysis of four randomized trials — ISAR TRIPLE, PIONEER AF-PCI, RE-DUAL PCI and WOEST — comparing bleeding and ischemic outcomes of dual antithrombotic therapy, defined as an anticoagulant and a P2Y12 inhibitor, with triple therapy in patients with AF after PCI.
Of the 5,317 patients in the trials, 57% received dual therapy.
TIMI major or minor bleeding was 47% lower in the dual-therapy group (4.3% vs. 9%; HR = 0.53; 95% credible interval [CrI], 0.36-0.85; I2 = 42.9%), the researchers found. Risk for intracranial bleeding was numerically lower in the dual-therapy group but not statistically significant (HR = 0.58; 95% CrI, 0.23-1.49; I2 = 0%).
However, there was no difference between the groups in MACE (dual-therapy group, 10.4%; triple-therapy group, 10%; HR = 0.85; 95% CrI, 0.48-1.29; I2 = 58.4%), according to the researchers.
There were also no differences between the groups in all-cause mortality (HR = 0.85; 95% CrI, 0.46-1.37; I2 = 39.3%), cardiac death (HR = 0.89; 95% CrI, 0.41-1.54; I2 = 28.7%), stent thrombosis (HR = 1; 95% CrI, 0.32-2.82; I2 = 32.1%), MI (HR = 1.07; 95% CrI, 0.58-1.95; I2 = 15.8%) and stroke (HR = 0.94; 95% CrI, 0.45-1.84; I2 = 0%), Golwala and colleagues wrote.
“Our study demonstrates that [dual antithrombotic therapy] is better than [triple antithrombotic therapy] for bleeding outcomes and comparable to [triple antithrombotic therapy] for efficacy outcomes,” the researchers wrote. “Taking this a step further, the major question that yet remains unanswered is the most appropriate combination for [dual antithrombotic therapy] ... which provides us with the right balance for minimizing thromboembolic vs. bleeding risks in an individual patient. With several such combinations possible, future trials are needed to answer these critical questions.” – by Erik Swain
Disclosures: Golwala reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
Back to Top
Chandan Devireddy, MD, FACC, FSCAI
Although several studies have demonstrated benefits of dual therapy vs. triple therapy, there has been some skepticism regarding the statistical power of these individual trials to evaluate the ability of dual therapy to prevent stent thrombosis or MACE. This elegant meta-analysis adds greater weight of evidence that routine PCI outcomes are not adversely affected by adoption of dual therapy in patients needing systemic anticoagulation. In fact, this meta-analysis provides strong evidence that patients have significantly reduced risk of TIMI minor and major bleed with dual therapy.
I think the results provided by Golwala and colleagues will impact the practice of interventional cardiologists greatly, as patients requiring systemic anticoagulation are encountered much more frequently as the population ages and the prevalence of AF increases.
Although the data are solid, there are many types of complex PCI that are not represented in this trial and do give pause as to whether the performance of dual therapy in this meta-analysis can be extrapolated to patients undergoing left main stenting or complex bifurcation techniques in which the specter of stent thrombosis is much more worrisome. This will require an informed discussion between physician and patient as to whether dual therapy is right or whether the risk for stent thrombosis outweighs the risk for bleeding.
Another important point raised by the authors is that within dual-therapy and triple-therapy regimens, there may be tremendous heterogeneity between clopidogrel, prasugrel (Effient, Daiichi Sankyo/Eli Lilly) and ticagrelor (Brilinta, AstraZeneca) and their combination with warfarin or direct oral anticoagulants in their potential for bleeding and reduction in MACE events. We don’t have the evidence base yet to know if there is any preferred combination for certain types of patients. Hopefully we’ll have more science to help guide us in the years to come.
Click Here to Manage Email Alerts