HOT OFF THE PRESS!

Originally published as an update to Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th edition

Debra L. Beck and Eugene Braunwald, MD

Date Published: 10 Aug 2018

Safety and efficacy of dual vs triple antithrombotic therapy in patients with AF following PCI. A meta-analysis of randomized controlled trials

Oral anticoagulation (OAC) is superior to dual antiplatelet therapy (DAT) in preventing stroke in patients with atrial fibrillation (AF), but DAT is superior to OAC in preventing stent thrombosis and ischemic events after percutaneous coronary intervention (PCI). In the approximately 5-10% of patients with AF who undergo PCI, many are given treatment with both of these therapies, the so-called triple antithrombotic therapy (TAT) approach. Golwala et al conducted a systematic review and meta-analysis of phase 3 randomized trials that compared DAT vs. TAT in patients with AF following PCI.

A total of 5317 patients from 4 trials (WOEST, ISAR-TRIPLE, PIONEER AF-PCI, RE-DUAL PCI) were included. Mean follow-up ranged from 9 to 14 months and mean age was 70.9 years in the DAT group and 71.1 years in the TAT group. About half of each arm underwent PCI for acute coronary syndrome and the remainder underwent PCI for non-ACS indications.

Compared with TAT, TIMI major or minor bleeding was reduced by 47% with DAT (4.3% vs. 9.0%; hazard ratio (HR) 0.53; p<0.05). However, no difference was seen in individual trial-defined major adverse cardiac events (MACE; 10.4% vs. 10.0%, HR 0.85, p=NS), or in the individual outcomes of all-cause mortality, cardiac death, myocardial infarction, stent thrombosis, or stroke between the two arms.

Summary

The investigators concluded that, compared with TAT, DAT in patients with AF undergoing PCI is associated with less bleeding and comparable rates of major adverse cardiac outcomes, mortality, and stent thrombosis. This meta-analysis is consistent with previous efforts and supports “the concept that DAT may be a better option than TAT in many patients with AF following PCI.”

Comments

In an editorial, Drs. N Hammoudi and G Montalescot wrote, “while waiting for other ongoing randomized studies, these results are useful to the practitioners who need to treat high bleeding risk patients and cannot run the risk of triple therapy.” They also wrote that this patients subgroup (“AF-stented patients”) are “a good example of where changes in practice precede changes in guidelines” because DAT has yet to be endorsed by relevant guidelines. “Quitting aspirin at hospital discharge in these patients is not the first option in the guidelines but is becoming the preferred option for many practitioners.” they wrote.

References

1. HB Golwala, CP Cannon, PG Steg, et al.: Safety and efficacy of dual vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of randomized clinical trials. Eur Heart J. 39(19): 1726-1735a. 2018 May 14. 29668889
2. N Hammoudi, G Montalescot: The times they are a changin’. Eur Heart J. 39(19): 1736-1739. 2018 May 14. 29762701

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring twice monthly updates including “Hot off the Press” and Late-Breaking Clinical Trials (links to authors’ presentation slides are also included).

Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.