Abstract
Background
The choice of antithrombotic therapy for atrial fibrillation (AF) patients who have
an acute coronary syndrome (ACS) or have undergone percutaneous coronary intervention
(PCI) is challenging. We aimed to assess outcomes between dual-antithrombotic therapy
with the use of direct-acting oral anticoagulants (DOACs) plus an antiplatelet agent
(dual therapy) compared with warfarin plus 2 antiplatelet agents (triple therapy)
for AF patients after PCI or with ACS.
Methods
Systematic searches of multiple major databases were performed from their inception
through September 2019. We included only randomized controlled trials. Odds ratios
(ORs) were pooled with the use of a random-effects model.
Results
We identified 4 randomized controlled trials, which included 7168 patients. Compared
with triple-antithrombotic therapy with warfarin, dual-antithrombotic therapy with
DOACs was associated with a significant reduction in major bleeding (OR 0.56, 95%
confidence interval [CI] 0.38-0.82; P = 0.003) as well as major bleeding or clinically relevant nonmajor bleeding (OR 0.53,
95% CI 0.38-0.75; P < 0.001). The rate of composite of death and ischemic events (stroke and myocardial
infarction) was not statistically different between groups (OR 1.21, 95% CI 0.99-1.49;
P = 0.06). There was no significant difference between groups in the rate of death
(OR 1.20, 95% CI 0.95-1.53; P = 0.13).
Conclusions
In patients with AF and recent ACS or PCI, the use of dual-antithrombotic therapy
with DOACs was associated with less major bleeding and less major bleeding or clinically
relevant nonmajor bleeding compared with triple therapy. The use of dual therapy also
showed nonsignificantly higher composite of death and ischemic events but no difference
in mortality.
Résumé
Contexte
Il est difficile de choisir un traitement antithrombotique en cas de fibrillation
auriculaire (FA) chez les patients ayant subi un syndrome coronarien aigu (SCA) ou
une intervention coronarienne percutanée (ICP). Nous avons comparé les résultats obtenus
avec une bithérapie antithrombotique comprenant un anticoagulant oral direct (AOD)
et un antiplaquettaire (bithérapie) à ceux obtenus avec la warfarine associée à deux
antiplaquettaires (trithérapie) après une ICP ou un SCA chez des patients présentant
une FA.
Méthodologie
Nous avons effectué des recherches exhaustives dans plusieurs grandes bases de données
afin de retracer les études menées sur le sujet jusqu’en septembre 2019. Nous n’avons
tenu compte que des essais contrôlés avec répartition aléatoire. Les rapports de cotes
ont été regroupés à l’aide d’un modèle à effets aléatoires.
Résultats
Nous avons relevé quatre essais contrôlés avec répartition aléatoire menés auprès
d’un nombre total de 7168 patients. Comparativement à la trithérapie antithrombotique comprenant
de la warfarine, la bithérapie antithrombotique comprenant un AOD a été associée à
une réduction significative des hémorragies majeures (rapport de cotes [RC] de 0,56;
intervalle de confiance [IC] à 95 % : 0,38-0,82; p = 0,003) ainsi que des hémorragies majeures ou hémorragies non majeures importantes
sur le plan clinique (RC de 0,53 [IC à 95 % : 0,38-0,75], p < 0,001). Le taux du critère composé du décès ou d’un événement ischémique (accident
vasculaire cérébral ou infarctus du myocarde) ne différait pas de manière statistiquement
significative entre les deux groupes (RC de 1,21; IC à 95 % : 0,99-1,49, p = 0,06). Il n’y avait pas non plus de différence significative entre les deux groupes
quant au taux de décès (RC de 1,20; IC à 95 % : 0,95-1,53; p = 0,13).
Conclusions
Chez les patients présentant une FA et ayant récemment subi un SCA ou une ICP, l’emploi
d’une bithérapie antithrombotique comprenant un AOD a été associé à une diminution
des hémorragies majeures et des hémorragies majeures ou hémorragies non majeures importantes
sur le plan clinique, comparativement à l’emploi d’une trithérapie. Le recours à une
bithérapie était par ailleurs associé à une hausse non significative de la fréquence
des manifestations du critère composé du décès ou d’un événement ischémique; aucune
différence n’a été observée quant à la mortalité.
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Article info
Publication history
Published online: November 12, 2019
Accepted:
November 4,
2019
Received:
June 30,
2019
Footnotes
See page 141 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
