Department of Neurology, Section of Vascular and Neurological Critical Care, Baylor College of Medicine.
Department of Neurology, Section of Vascular and Neurological Critical Care, Baylor College of Medicine; David Geffen School of Medicine, Comprehensive Stroke Center, Department of Neurology, University of California, Los Angeles, Los Angeles.
J Stroke Cerebrovasc Dis. 2021 Apr;30(4):105654. doi: 10.1016/j.jstrokecerebrovasdis.2021.105654. Epub 2021 Feb 10.
About 15% of patients with non-valvular atrial fibrillation might require percutaneous coronary interventions (PCIs) with stent placement to treat obstructive coronary artery disease. Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (aspirin) and P2Y12 antagonist is recommended after PCI. Patients requiring DAPT also require treatment with oral anticoagulation for atrial fibrillation. We conducted a meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in non-valvular atrial fibrillation after PCI.
We searched PubMed, Embase, Scopus and Cochrane databases to identify randomized trials that investigated the use of dual antiplatelet therapy and vitamin K antagonist and/or Non-vitamin K antagonist oral anticoagulants (NOAC) (triple antithrombotic therapy (TAT)) against single antiplatelet agent and NOAC (dual antithrombotic therapy (DAT)) in the setting of coronary artery disease (CAD) requiring PCI and non-valvular atrial fibrillation. Random-effect models were used to pool data. We used the I statistic to measure heterogeneity between trials.
We found 4 randomized clinical trials (ENTRUST, AUGUSTUS, PIONEER, REDUAL) using different NOACs. Overall, 9241 patients (median age 70 years, 41.4% female, mean CHADS2VASC Score 3.5) were included. We excluded patients in the very low dose rivaroxaban group from the PIONEER AF-PCI trial and low dose dabigatran group from the REDUAL PCI trial as these are not available in the United States. Our metanalysis showed that dual therapy was associated with less risk of intracranial hemorrhage (RR 0.55, 95% CI 0.31-0.99; p = 0.045; I = 42%) and major bleeding (RR 0.66; 95% CI 0.55-0.79; p < 0.0001; I = 27%) as compared to triple therapy. Further risk of ischemic stroke (RR 0.94, 95% CI 0.63-1.39; p = 0.75; I=0%), myocardial infarction (RR 1.18, 95% CI 0.94-1.47; p = 0.16; I = 0), or stent thrombosis (RR 0.50, 95% CI 0.93-2.41; p = 0.10; I = 0%) were unchanged. Similar findings were also noted on analysis of NOAC specific DAT vs VKA based TAT.
The combination of an antiplatelet and NOACs (dual therapy) is associated with less risk of major bleeding and intracranial hemorrhage, with no significant difference in ischemic events (stroke myocardial infarction or stent thrombosis).
约 15%的非瓣膜性心房颤动患者可能需要经皮冠状动脉介入治疗 (PCI) 加支架置入术来治疗阻塞性冠状动脉疾病。PCI 后推荐使用乙酰水杨酸 (阿司匹林) 和 P2Y12 拮抗剂双联抗血小板治疗 (DAPT)。需要 DAPT 的患者还需要接受口服抗凝剂治疗心房颤动。我们进行了一项荟萃分析，以确定与 PCI 后非瓣膜性心房颤动最低出血和血栓栓塞事件发生率相关的抗血栓形成方案。
我们检索了 PubMed、Embase、Scopus 和 Cochrane 数据库，以确定随机试验，这些试验调查了双联抗血小板治疗和维生素 K 拮抗剂和/或非维生素 K 拮抗剂口服抗凝剂 (NOAC) (三联抗栓治疗 (TAT)) 与单药抗血小板药物和 NOAC (双联抗栓治疗 (DAT)) 在需要 PCI 的冠状动脉疾病 (CAD) 和非瓣膜性心房颤动中的应用。使用随机效应模型对数据进行汇总。我们使用 I ² 统计量来衡量试验之间的异质性。
我们发现了 4 项使用不同 NOAC 的随机临床试验 (ENTRUST、AUGUSTUS、PIONEER、REDUAL)。总体而言，纳入了 9241 名患者 (中位年龄 70 岁，41.4%为女性，平均 CHADS2VASC 评分 3.5)。我们排除了 PIONEER AF-PCI 试验中极低剂量利伐沙班组和 REDUAL PCI 试验中低剂量达比加群组的患者，因为这些药物在美国不可用。我们的荟萃分析显示，与三联治疗相比，双联治疗与颅内出血风险降低相关 (RR 0.55，95%CI 0.31-0.99；p=0.045；I=42%) 和主要出血 (RR 0.66；95%CI 0.55-0.79；p<0.0001；I=27%)。进一步的缺血性卒中风险 (RR 0.94，95%CI 0.63-1.39；p=0.75；I=0%)、心肌梗死 (RR 1.18，95%CI 0.94-1.47；p=0.16；I=0%) 或支架血栓形成 (RR 0.50，95%CI 0.93-2.41；p=0.10；I=0%) 无显著变化。对特定的 NOAC 双联治疗与 VKA 三联治疗的分析也得出了类似的结果。
抗血小板药物加 NOACs (双联治疗) 与大出血和颅内出血风险降低相关，缺血事件 (卒中、心肌梗死或支架血栓形成) 无显著差异。
