title: Meta-analysis of randomized controlled trials and adjusted observational results of use of clopidogrel, aspirin, and oral anticoagulants in patients undergoing percutaneous coronary intervention.
abstract: The optimal antiaggregant therapy after coronary stenting in patients receiving oral anticoagulants (OACs) is currently debated. MEDLINE and Cochrane Library were searched for studies reporting outcomes of patients who underwent PCI and who were on triple therapy (TT) or dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel or dual therapy (DT) with OAC and clopidogrel. Major bleeding was the primary end point, whereas all-cause death, myocardial infarction (MI), stent thrombosis, and stroke were secondary ones. Results were reported for all studies and separately for those deriving from randomized controlled trials or multivariate analysis. In 9 studies, 1,317 patients were treated with DAPT and 1,547 with TT. DAPT offered a significant reduction of major bleeding at 1 year for overall studies and for the subset of observational works providing adjusted data (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.39 to 0.68, I2 60% and OR 0.36, 95% CI 0.28 to 0.46) compared to TT. No increased risk of major adverse cardiac events (MACE: death, MI, stroke, and stent thrombosis) was reported (OR 0.71, 95% CI 0.46 to 1.08), although not deriving from randomized controlled trials or multivariate analysis. Six studies tested OAC and clopidogrel (1,263 patients) versus OAC, aspirin, and clopidogrel (3,055 patients) with a significant reduction of bleeding (OR 0.79, 95% CI 0.64 to 0.98), without affecting rates of death, MI, stroke, and stent thrombosis (OR 0.90, 95% CI 0.69 to 1.23) also when including clinical data from randomized controlled trials or multivariate analysis. In conclusion, compared to TT, both aspirin and clopidogrel and clopidogrel and OAC reduce bleeding. No difference in major adverse cardiac events is present for clopidogrel and OAC, whereas only low-grade evidence is present for aspirin and clopidogrel.
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Fabrizio
authors: F
authors: D'Ascenzo
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy; Department of Cardiology, Assiut University Hospital, Assiut, Egypt. Electronic address: esmaeil.salma@gmail.com.
authors: Salma
authors: S
authors: Taha
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Claudio
authors: C
authors: Moretti
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Pierluigi
authors: P
authors: Omedè
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Walter
authors: W
authors: Grossomarra
authors: Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.
authors: Jonas
authors: J
authors: Persson
authors: Department of Cardiology, Copenhagen University Hospital Gentofte, Denmark.
authors: Morten
authors: M
authors: Lamberts
authors: Department of Cardiology, Twee Steden Hospital, Tilburg, Netherlands.
authors: Willem
authors: W
authors: Dewilde
authors: Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy.
authors: Andrea
authors: A
authors: Rubboli
authors: Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain.
authors: Sergio
authors: S
authors: Fernández
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Enrico
authors: E
authors: Cerrato
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Ilaria
authors: I
authors: Meynet
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Flavia
authors: F
authors: Ballocca
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Umberto
authors: U
authors: Barbero
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Giorgio
authors: G
authors: Quadri
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Francesca
authors: F
authors: Giordana
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Federico
authors: F
authors: Conrotto
authors: Department of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy.
authors: Davide
authors: D
authors: Capodanno
authors: Mid America Heart Institute, St. Luke's Hospital, Kansas City, Missouri.
authors: James
authors: J
authors: DiNicolantonio
authors: Department of Medicine, Division of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York.
authors: Sripal
authors: S
authors: Bangalore
authors: Emergency Department, Royal infirmary of Edinburgh, Edinburgh, United Kingdom.
authors: Matthew
authors: M
authors: Reed
authors: The Heart Hospital, University College London Hospital, London, United Kingdom.
authors: Pascal
authors: P
authors: Meier
authors: Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome, Latina, Italy.
authors: Giuseppe
authors: G
authors: Zoccai
authors: Division of Cardiology, Department of Internal Medicine, Città della Salute e Della Scienza, University of Turin, Turin, Italy.
authors: Fiorenzo
authors: F
authors: Gaita
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001241:Aspirin / Q000008:administration & dosage* / Q000009:adverse effects; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D006470:Hemorrhage / Q000517:prevention & control; D006801:Humans; D017202:Myocardial Ischemia / Q000628:therapy*; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D016032:Randomized Controlled Trials as Topic; D015607:Stents; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin