Efficacy and safety of long-term antithrombotic strategies in patients with chronic coronary syndrome: A network meta-analysis of randomized controlled trials

Abstract

BACKGROUND: Long-term antithrombotic strategies for patients with chronic coronary syndrome with high-risk factors repre-sent an important treatment dilemma in clinical practice. Our aim was to conduct a network meta-analysis to evaluate the efficacy and safety of long-term antithrombotic strategies in patients with chronic coronary syndrome. METHODS AND RESULTS: Four randomized studies were included (n=75167; THEMIS [Ticagrelor on Health Outcomes in Diabetes Mellitus Patients Intervention Study], COMPASS [Cardiovascular Outcomes for People Using Anticoagulation Strategies], PEGASUS-TIMI 54 [Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin–Thrombolysis in Myocardial Infarction 54], and DAPT [Dual Anti-platelet Therapy]). The odds ratios (ORs) and 95% CIs) were calculated as the measure of effect size. The results of the network meta-analysis showed that, compared with aspirin monotherapy, the ORs for trial-defined major adverse cardiovascular and cerebrovascular events were 0.86; (95% CI, 0.80– 0.93) for ticagrelor plus aspirin, 0.89 (95% CI, 0.78– 1.02) for rivaroxaban monotherapy, 0.74 (95% CI, 0.64– 0.85) for rivaroxaban plus aspirin, and 0.72 (95% CI, 0.60,– 0.86) for thienopyridine plus aspirin. Compared with aspirin monotherapy, the ORs for trial-defined major bleeding were 2.15 (95% CI, 1.78– 2.59]) for ticagrelor plus aspirin, 1.51 (95% CI, 1.23–1.85) for rivaroxaban monotherapy, and 1.68 (95% CI, 1.37– 2.05) for rivaroxaban plus aspirin. For death from any cause, the improvement effect of rivaroxaban plus aspirin was detected versus aspirin monotherapy (OR, 0.76; 95% CI, 0.65– 0.90), ticagrelor plus aspirin (OR, 0.79; 95% CI, 0.66– 0.95), rivaroxaban monotherapy (OR, 0.82; 95% CI, 0.69– 0.97), and thienopyridine plus aspirin (OR, 0.58; 95% CI, 0.41– 0.82) regimens. CONCLUSIONS: All antithrombotic strategies combined with aspirin significantly reduced the incidence of major adverse cardiovascular and cerebrovascular events and increased the risk of major bleeding compared with aspirin mono-therapy. Considering the outcomes of all ischemic and bleeding events and all-cause mortality, rivaroxaban plus aspirin appears to be the preferred long-term antithrombotic regimen for patients with chronic coronary syndrome and high-risk factors.