Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China.
Department of Cardiology, Chongqing Emergency Medical Center, Chongqing, P. R. China.
PLoS One. 2018 Jun 19;13(6):e0199232. doi: 10.1371/journal.pone.0199232. eCollection 2018.
The optimal antithrombotic therapy for atrial fibrillation (AF) patients undergoing coronary stenting is unknown. The present meta-analysis sought to investigate the efficacy and safety of triple therapy (TT; warfarin, clopidogrel and aspirin) vs dual antiplatelet therapy (DAPT; clopidogrel plus aspirin) in those patients.
PubMed and Cochrane Library were searched for studies enrolling AF patients undergoing coronary stenting on TT and DAPT up to September 2016, and fourteen studies were included. Efficacy outcomes included ischemic stroke, stent thrombosis, major adverse cardiovascular event (MACE), all-cause mortality and myocardial infarction (MI); safety outcome was major bleeding. We conducted meta-analysis and used odds ratio (OR) with 95% confidence intervals (CI) to compare TT and DAPT. Meta-regression, sensitivity and subgroup analysis were taken to investigate the source of heterogeneity in the outcome of major bleeding.
14 eligible observational studies with 11,697 subjects were identified. Compared with DAPT, TT had decreased the risk of ischemic stroke [OR = 0.74, 95% CI (0.59, 0.93), P = 0.009] and stent thrombosis [OR = 0.40, 95% CI (0.18, 0.93), P = 0.033]. While, there was an increased risk of major bleeding [OR = 1.55, 95% CI (1.16, 2.09), P = 0.004] associated with TT. The risk of MACE, all-cause mortality and MI had no significant statistical difference between TT and DAPT. Furthermore, the results of univariate and multivariate meta-regression analysis implicated that there were no obvious correlations between certain baseline characteristics (age, gender, race, hypertension, study design) and risk of major bleeding. Also of major bleeding, the findings of sensitivity analysis were generally robust, and a prespecified subgroup analysis of race demonstrated that the source of heterogeneity might attribute to Asian studies mostly.
TT reduced the risk of ischemic stroke and stent thrombosis with an acceptable major bleeding risk compared with DAPT, and TT was considered as a valid alternative in AF patients undergoing coronary stenting. Further prospective randomized trials are needed to ensure the reliability of these data and find the optimal therapeutic strategy in this setting of patients.
对于接受冠状动脉支架置入术的心房颤动（AF）患者，最佳的抗血栓治疗方法尚不清楚。本荟萃分析旨在研究三联抗栓治疗（TT；华法林、氯吡格雷和阿司匹林）与双联抗血小板治疗（DAPT；氯吡格雷加阿司匹林）在这些患者中的疗效和安全性。
检索 PubMed 和 Cochrane Library 数据库，纳入截至 2016 年 9 月接受 TT 和 DAPT 的 AF 患者接受冠状动脉支架置入术的研究，共纳入 14 项研究。疗效结局包括缺血性卒中、支架血栓形成、主要不良心血管事件（MACE）、全因死亡率和心肌梗死（MI）；安全性结局为大出血。我们进行荟萃分析，并使用比值比（OR）及其 95%置信区间（CI）来比较 TT 和 DAPT。采用Meta 回归、敏感性分析和亚组分析来探讨大出血结局异质性的来源。
共纳入 14 项符合条件的观察性研究，共计 11697 例患者。与 DAPT 相比，TT 降低了缺血性卒中和支架血栓形成的风险[OR=0.74，95%CI（0.59，0.93），P=0.009]和[OR=0.40，95%CI（0.18，0.93），P=0.033]。然而，TT 与大出血风险增加相关[OR=1.55，95%CI（1.16，2.09），P=0.004]。TT 与 DAPT 相比，MACE、全因死亡率和 MI 的风险无统计学差异。此外，单变量和多变量 Meta 回归分析的结果表明，某些基线特征（年龄、性别、种族、高血压、研究设计）与大出血风险之间无明显相关性。同样是大出血，敏感性分析的结果基本稳健，预先设定的种族亚组分析表明，异质性的来源可能主要归因于亚洲研究。
与 DAPT 相比，TT 降低了缺血性卒中和支架血栓形成的风险，同时大出血风险可接受，TT 被认为是接受冠状动脉支架置入术的 AF 患者的一种有效替代方法。需要进一步的前瞻性随机试验来确保这些数据的可靠性，并找到该患者人群的最佳治疗策略。
