Ischemic and bleeding outcomes of triple therapy in patients on chronic anticoagulation undergoing percutaneous coronary intervention: A meta-analysis of randomized trials

Abstract

Background: Triple therapy (TT) that include warfarin or non-vitamin K oral anticoagulant (NOAC) and dual antiplatelet therapy (DAPT) is recommended in patients who are on chronic anticoagulation and undergo percutaneous coronary intervention (PCI). DAPT is superior to prevent ischemic outcomes after PCI whereas an anticoagulant is superior for stroke prevention in the patients with atrial fibrillation. The randomized controlled trials (RCTs) comparing the effectiveness and safety of TT have shown increased risk of bleeding; however, none of the individual studies were powered to show a difference in ischemic outcomes compared to double therapy (DT). To compare the clinical outcomes of TT and DT, we performed this metaanalysis of RCTs. Methods: Databases were searched electronically for RCTs comparing TT and DT in patients who were on oral anticoagulation and underwent PCI. Mortality, major bleeding, myocardial infarction (MI), stroke and stent thrombosis (ST) were the major outcomes. Results: A total of 4 trials (5993 patients) were included in the metaanalysis. TT, compared to DT, resulted in higher risk of major bleeding [odds ratio (OR); 1.61; 95% confidence interval (CI): (1.09-2.37); P=0.02) and similar risk of mortality [1.20(0.78-1.84); P=0.41], MI [0.88 (0.64-1.21); P=0.42], stroke [1.16 (0.68-1.97); P=0.08] and ST [1.02 (0.50-2.05); P=0.96]. Conclusion: The current meta-analysis does not support the use of triple therapy in patients who are on chronic anticoagulation and undergo percutaneous coronary intervention owing to increased risk of major bleeding without advantage over ischemic outcomes.