Fake Aimee, Ranchord Anil, Harding Scott, Larsen Peter
University of Otago, Wellington. 23A Mein St, Newtown, Wellington, New Zealand.
Wellington Cardiovascular Research Group, Wellington, New Zealand.
Curr Cardiol Rev. 2017;13(4):325-333. doi: 10.2174/1573403X13666170927121808.
Patients with acute coronary syndromes (ACS) and a history of atrial fibrillation (AF) have indications for both dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC). Triple therapy (TT), the combination of DAPT and OAC, is recommended in guidelines. We examined studies comparing clinical outcomes on DAPT versus TT for patients with AF and ACS.
We searched Medline, Medline pending, EMBASE and Evidence-Based Medicine Reviews databases for studies published between January 2000 to December 2016 in AF patients with ACS that compared DAPT and TT that reported ischaemic and/or bleeding outcomes. Studies that were not purely an AF population were excluded.
Ten studies were included in the review, all of which were observational, 8 of which were retrospective. None of the studies detailed the specifics of treatment allocation. All but one were of AF patients with a mix of stable coronary disease and ACS patients. TT was associated with increased bleeding when compared to DAPT, with adjusted odds ratios ranging from 1.25 to 6.84. While the largest study reported a reduction in stroke associated with TT (odds ratio 0.67), two other studies reported non-significant increases in stroke with TT. Variable composite ischaemic endpoints were reported, none showing a statistical significant difference between DAPT and TT.
In patients with ACS and AF, TT is likely to be associated with increased risk of bleeding, without a clear reduction in ischaemic endpoints. The quality of the evidence to support current guidelines for this patient group was generally poor.
患有急性冠状动脉综合征(ACS)且有房颤(AF)病史的患者有接受双联抗血小板治疗(DAPT)和口服抗凝治疗(OAC)的指征。指南推荐采用三联疗法(TT),即DAPT与OAC联合使用。我们研究了比较AF合并ACS患者DAPT与TT临床结局的研究。
我们检索了Medline、Medline待发表文献、EMBASE和循证医学综述数据库,以查找2000年1月至2016年12月期间发表的、比较AF合并ACS患者DAPT与TT并报告缺血和/或出血结局的研究。排除并非单纯AF人群的研究。
该综述纳入了10项研究,均为观察性研究,其中8项为回顾性研究。没有一项研究详细说明治疗分配的具体情况。除一项研究外,其余均为AF合并稳定型冠心病和ACS患者。与DAPT相比,TT与出血增加相关,调整后的优势比在1.25至6.84之间。虽然最大的研究报告TT可降低卒中风险(优势比0.67),但其他两项研究报告TT导致卒中无显著增加。报告了多种复合缺血终点,均未显示DAPT与TT之间存在统计学显著差异。
对于ACS合并AF患者,TT可能与出血风险增加相关,且缺血终点无明显降低。支持该患者群体当前指南的证据质量普遍较差。