Evaluation of the efficacy and safety of dual antiplatelet therapy with or without warfarin in patients with a clinical indication for DAPT and chronic anticoagulation: A meta-analysis of observational studies.
OBJECTIVE
To compare the efficacy and safety of dual antiplatelet therapy (DAPT) and triple therapy (TT, dual antiplatelet plus warfarin) in patients with myocardial infarction (MI) or PCI with stenting (PCI-S) who also require chronic oral anticoagulation.


BACKGROUND
Recommendations for the optimal antiplatelet/anticoagulant treatment regimen for patients undergoing PCI-S or MI who also require oral anticoagulation are largely based on evidence from observational studies and expert opinions.


METHODS
A systematic search was performed for studies comparing TT vs. DAPT in patients post PCI-S or MI and requiring chronic anticoagulation. Primary outcome was all-cause mortality. Secondary outcomes were ischemic stroke, major bleeding, MI, and stent thrombosis. Pooled relative risks (RR) were calculated using random effects model.


RESULTS
A total of 17 studies were included, with 14,921 patients [TT: 5,819(39%) and DAPT: 9,102(61%)] and a mean follow-up of 1.6 years. The majority of patients required oral anticoagulation for atrial fibrillation. Compared to DAPT, patients treated with TT had no significant difference in all-cause mortality [RR: 0.81, 95% confidence interval (CI): 0.61-1.08, P = 0.15], MI [RR 0.74, 95% CI: 0.51-1.06, P = 0.10], and stent thrombosis [RR 0.67, 95% CI: 0.35-1.30, P = 0.24]. Patients treated with TT had significantly increased risk of major bleeding [RR 1.20, 95% CI: 1.03-1.39, P = 0.02], whereas the risk for ischemic stroke was significantly lower [RR 0.59, 95% CI: 0.38-0.92, P = 0.02].


CONCLUSIONS
All-cause mortality appears similar in patients treated with TT or DAPT although TT was associated with higher rates of major bleeding and a lower risk for ischemic stroke. © 2015 Wiley Periodicals, Inc.
Mount Sinai St. Luke's and Roosevelt Hospitals, New York, New York.
Chirag
C
Bavishi
Mount Sinai St. Luke's and Roosevelt Hospitals, New York, New York.
Anna
A
Koulova
New York University School of Medicine, New York, New York.
Sripal
S
Bangalore
Mount Sinai St. Luke's and Roosevelt Hospitals, New York, New York.
Ashwin
A
Sawant
Mount Sinai St. Luke's and Roosevelt Hospitals, New York, New York.
Saurav
S
Chatterjee
University of Alabama at Birmingham, Birmingham, Alabama.
Sameer
S
Ather
General Hospital University of Alicante, Alicante, Spain.
Jose
J
Valencia
Klinikum Der Ludwig-Maximilians-Universität, Munich, Germany.
Nikolaus
N
Sarafoff
Division of Cardiology, Ospedale Maggiore, Bologna, Italy.
Andrea
A
Rubboli
Turku University Hospital and University of Turku Heart Center, Turku, Finland.
Juhani K
JK
Airaksinen
Department of Clinical Medicine, University of Birmingham, Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.|Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark.
Gregory Y H
GY
Lip
Mount Sinai St. Luke's and Roosevelt Hospitals, New York, New York.
Jacqueline E
JE
Tamis-Holland
D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D016009:Chi-Square Distribution; D015897:Comorbidity; D004359:Drug Therapy, Combination; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D064887:Observational Studies as Topic; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000517:prevention & control; D016896:Treatment Outcome; D014859:Warfarin / Q000008:administration & dosage* / Q000009:adverse effects
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D014859:Warfarin
ACS; ACS/MSTEMI; META; dual antiplatelet therapy DAPT; meta-analysis; triple therapy TT