P5505The efficacy and safety of the use of drug-eluting stents vs bare metal stents stratifying by antithrombotic therapy in atrial fibrillation patients undergoing coronary stenting: a systematic review

Abstract

Background: Patients with atrial fibrillation (AF) requiring percutaneous coronary intervention (PCI) are exposed to aggressive antithrombotic regimes. The new ESC guidelines recommend the use of drug-eluting stents (DES) in these patients based on current evidence. Purpose: The aims of our study were to analyze the efficacy and safety between the use of DES compared to bare metal stents (BMS) stratifying by antithrombotic therapy. Methods: We performed a systematic review and meta-analysis of studies comparing DES vs BMS in AF patients undergoing PCI with stent placement for acute coronary syndromes (ACS) or stable ischemic heart disease. We stratified by: a. type of antithrombotic therapy (Triple Teraphy:TT, DAPT: dual antiplatelet therapy or Dual therapy: DT) and b. duration of antithrombotic therapy (short and long-term). Primary outcome of efficacy was major adverse cardiovascular events (MACE) and of safety was major bleeding.We used random effects meta-analysis using inverse variance or Mantel-Haenzel methods for common or rare outcomes, respectively. Our measure of effect was relative risk (RR) and its 95% confidence interval (CI). Results: Six studies were selected (five cohort studies, one RCT) with 1,170 DES and 1,104 BMS patients. There was a non-significant differences in the incidence of MACE between patients on TT between DES and BMS. TT long-term treatment showed a similar risk of MACE (190/949 [20%] vs 38/180 [21.1%] RR 0.96 95% IC 0.69-1.33, p=0.80). However, there was a trend a reduced risk of MACE in patients on TT short-term in DES vs BMS (59/403 [14.6%] vs 174/957 [18.1%] RR 1.32 95% IC 0.99-1.75, p=0.06). DAPT long and short-term showed a similar risk of MACE between DES vs BMS: (p=0.78; p=0.27), respectively. DT long-term showed a reduction in the risk of MACE in favor of DES vs BMS (6/32 [14.2%] vs 14/35 [19.5%] RR 0.45 95% IC 0.20-1.01, p=0.05) and DT at short-term was prescribed in few cases (4/5 [14.2%] vs 13/22 [19.5%] RR 1.35 95% IC 0.77-2.37, p=0.29). The risk of major bleeding in patients on TT long-term was similar between DES and BMS, although there was a trend to be higher in BMS (40/949 [4.2%] vs 14/180 [7.8%] RR 0.87 95% IC 0.48-1.61, p=0.67) as well as in patients on TT short-term with BMS (13/403 [3.2%] vs 71/957 [7.4%] RR 1.55 95% IC 0.49-4.97, p=0.46). Similarly, few patients on DT long-term did not show differences in the risk of major bleeding (p=0.46). Neither in dual therapy short-term (p=0.68). Conclusions: In our meta-analysis we observe no differences between the use of DES and BMS stratifying by antithrombotic treatment regarding MACE and the presence of major bleeding events. Few cases on DT did not allow stablish conclusions at this respect. The heterogeneity of the definitions, bias in the selection of population and the fact of most bleeding events occur during the first 30-days after PCI could explain these results.