Single vs. dual antithrombotic therapy in patients with stabilized coronary artery disease requiring long-term oral anticoagulation: A Bayesian meta-analysis
A Ibrahim, A Al-Shammari, S Ramadan, Y Kurmasha, K Hamzah, M R Islam, M Younas, H Jain, Y Sattar, P Sabouret, G AndoAbstract
Background
The management of antithrombotic therapy in patients with stable coronary artery disease (CAD) requiring long-term oral anticoagulation (OAC), primarily for atrial fibrillation, poses a significant clinical challenge due to the need to balance thrombotic and bleeding risks.
Aim
This Bayesian meta-analysis aimed to compare the efficacy and safety of OAC monotherapy versus combination therapy (OAC plus single antiplatelet therapy [SAPT]) in patients with stable CAD requiring long-term OAC.
Methods
A systematic literature search was conducted in PubMed, Scopus, Web of Science, and Embase up to September 2025 for randomised controlled trials (RCTs) comparing OAC monotherapy with combination therapy in the target population. Data on primary outcomes (major adverse cardiovascular events [MACE], net adverse clinical events [NACE], and major bleeding) were extracted. A Bayesian random-effects meta-analysis was performed with vague priors specified for the pooled effect (normal(mean=0, sd=2)) and between-study heterogeneity (half-normal(scale=0.5)). Results are presented as posterior mean risk ratios (RR) with 95% credible intervals (CrI), and the probability of benefit was calculated as the posterior probability of benefit (PPoB) that RR <1.
Results
Six studies (5,924 patients) were included. OAC monotherapy demonstrated a high probability of benefit for safety outcomes, with strong evidence for reducing ISTH major bleeding (RR 0.48, 95% CrI 0.31–0.72; PPoB: 99.8%) and major or clinically relevant non-major bleeding (RR 0.43, 95% CrI 0.28–0.66; PPoB: 99.8%). For composite efficacy-safety outcomes, OAC monotherapy reduced trial-defined NACE (RR 0.64, 95% CrI 0.46–0.88; PPoB: 99.3%) and showed a high probability of benefit for MACE (RR 0.85, 95% CrI 0.66–1.09; PPoB: 89.4%). Mortality outcomes, including all-cause death (RR 0.80, 95% CrI 0.53–1.28; PPoB: 86.9%) and cardiovascular death (RR 0.75, 95% CrI 0.50–1.21; PPoB: 91.1%), favoured OAC monotherapy. Ischaemic stroke and myocardial infarction demonstrated neutral effects.
Conclusion
In patients with stable CAD requiring long-term OAC, OAC monotherapy demonstrates superior net clinical benefit and should be considered the standard of care, as combination therapy provides no additional protection against ischaemic events while substantially increasing the risk of bleeding.Forest Plot For all Outcomes