Oral anticoagulation monotherapy versus dual antithrombotic therapy in chronic coronary syndrome patients requiring long-term anticoagulation: a bayesian meta-analysis of randomised controlled trials

Background

Oral anticoagulation (OAC) monotherapy is recommended for patients with chronic coronary syndrome (CCS) requiring long-term anticoagulation. Recent trials suggest a mortality benefit not demonstrated previously. We conducted a Bayesian meta-analysis to quantify probabilities of benefit.

Methods

PubMed, Embase, and CENTRAL were searched to January 2026 for randomised controlled trials comparing OAC monotherapy with dual antithrombotic therapy (DATT) in CCS patients requiring long-term anticoagulation. Bayesian random-effects models used weakly informative priors for treatment effects and outcome-specific heterogeneity priors; robustness was assessed with sensitivity analyses using non-informative priors. Primary outcomes were all-cause death and major bleeding. Secondary outcomes were major adverse cardiovascular events (MACE), myocardial infarction (MI), ischaemic stroke, all stroke, major or clinically relevant non major bleeding, and net adverse clinical events (NACE). Results are reported as risk ratios (RR) with 95% credible intervals (CrI) and probabilities of superiority.

Results

Six trials (5924 participants) were included. OAC monotherapy was associated with likely reduced all-cause death (RR 0.77, 95% CrI 0.58–1.07; 94.6% probability of superiority) and significantly reduced major bleeding (RR 0.51, 95% CrI 0.36–0.69; 100%). Cardiovascular death favoured OAC monotherapy (RR 0.73; 95% CrI 0.53 - 1.06; 95.4%), as did major or clinically relevant non major bleeding (RR 0.50; 95% CrI 0.37–0.65; 100%) and net adverse clinical events (RR 0.64; 95% CrI 0.49–0.82; 99.8%). There was inconclusive evidence for MACE (RR 0.88, 95% CrI 0.68–1.14; 86.0%), MI (RR 1.03, CrI 0.62–1.70; 45.9%), ischaemic stroke (RR 1.07, 95% CrI 0.71–1.68; 36.8%), and all stroke (RR 1.12; 95% CrI 0.68–1.86; 33.1%). Between-study heterogeneity was low to moderate; findings were robust in sensitivity analyses.CRD420260533373

Conclusions

In CCS patients requiring long-term anticoagulation, OAC monotherapy significantly reduces bleeding and demonstrates high probability of mortality benefit compared with DATT, without increased ischaemic risk, supporting its use as the preferred antithrombotic strategy.

Registration: PROSPERO CRD420260533373mainplotabstract.jpegfig2abstract.jpeg