Efficacy and safety of antithrombotic strategies for atrial fibrillation in patients with chronic coronary syndrome according to coronary treatment strategy: a meta-analysis of randomized trials
H Hendrianus, S Y Lee, J H Cho, J H Jo, S Honda, S Yasuda, D A Gorog, U S Tantry, P A Gurbel, S Soerianata, S W Kim, Y H JeongAbstract
Background
Because prior evidence has involved heterogeneous anticoagulant regimens and coronary treatment strategies, the optimal antithrombotic strategy for atrial fibrillation (AF) in patients with chronic coronary syndrome (CCS) remains uncertain.
Purpose
To evaluate the efficacy and safety of oral anticoagulant (OAC) monotherapy versus OAC plus single antiplatelet therapy (SAPT) in patients with AF and CCS, stratified by anticoagulant type and coronary treatment strategy.
Methods
We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding, and net adverse clinical events (NACE). Subgroup-specific data were extracted when trials included heterogeneous anticoagulant types or coronary treatment strategies. The study was prospectively registered in PROSPERO.
Results
Six RCTs including 5,924 patients were analyzed. Anticoagulant type significantly modified treatment effect (P for interaction = 0.02). Direct oral anticoagulant (DOAC) monotherapy reduced MACCE compared with DOAC plus SAPT (HR 0.72; 95% CI 0.59–0.88; P = 0.002), whereas vitamin K antagonist monotherapy showed no significant difference (HR 1.22; 95% CI 0.83–1.78; P = 0.32). DOAC monotherapy also significantly reduced major bleeding (HR 0.47; 95% CI 0.35–0.64; P < 0.00001) and NACE (HR 0.58; 95% CI 0.49–0.68; P < 0.00001). Treatment effect differed by coronary treatment strategy (P for interaction = 0.03). In patients with prior coronary revascularization, DOAC monotherapy reduced MACCE, driven by those with prior percutaneous coronary intervention (PCI), in whom MACCE was reduced by 34% (HR 0.66; 95% CI 0.53–0.83; P = 0.0004), whereas no benefit was observed with medical therapy alone (HR 1.26; 95% CI 0.73–2.17; P = 0.40). In prior PCI, DOAC monotherapy also reduced major bleeding (HR 0.42; 95% CI 0.27–0.66; P = 0.0001), NACE (HR 0.61; 95% CI 0.52–0.72; P < 0.00001), all-cause mortality (HR 0.57; 95% CI 0.43–0.77; P = 0.0002), and cardiovascular mortality (HR 0.50; 95% CI 0.34–0.73; P = 0.0004), without differences in myocardial infarction or stroke.
Conclusions
In patients with AF and CCS, the efficacy and safety of OAC monotherapy vary according to anticoagulant type and coronary treatment strategy. Compared with DOAC plus SAPT, DOAC monotherapy reduces mortality and major bleeding, with benefits most evident in patients with prior PCI.Figure 1Figure 2