META Analysis Of Antithrombotic Strategy In Patients With Atrial Fibrillation And Coronary Atherosclerotic Heart Disease Undergoing PCI

[Background]As the population ages and living conditions continue to improve,the prevalence and incidence of atrial fibrillation(AF)and coronary atherosclerotic heart disease(CHD)are on the rise.Atrial fibrillation is the most common arrhythmia in clinical practice.And atrial fibrillation is associated with increased morbidity and mortality risk.Its major complication is ischemic stroke,so that most patients require long-term oral anticoagulant antithrombotic therapy.Percutaneous coronary intervention(PCI)has become one of the most important and effective methods for patients with coronary heart disease,especially with acute coronary syndrome.But,postoperative stent thrombosis and coronary events still have a high incidence,which makes the perioperative period and postoperative anticoagulation and antiplatelet therapy appear to be particularly important.Currently,patients with atrial fibrillation undergoing PCI require oral anticoagulant therapy to prevent ischemic stroke as well as dual antiplatelet therapy to prevent stent thrombosis and coronary events,which makes antithrombotic therapy become much more complicated.Minimizing the risk of bleeding while maximizing the benefits of antithrombotic therapy is the key to formulating anticoagulant therapy for these patients.So far,due to the difficulty in balancing the increased risk of bleeding and the complications of thromboembolism,the limited evidence in clinical studies,and the lack of evidence in evidence-based medicine,there is still no consensus about the optimal antithrombotic strategy to choose in this kind of patients.In recent years,the best antithrombotic therapy for patients with atrial fibrillation and coronary atherosclerotic heart disease undergoing PCI becomes an emerging clinical problem.[Object]To compare the efficacy and safety of dual antithrombotic therapy and triple antithrombotic therapy in patients with atrial fibrillation complicated with coronary atherosclerotic heart disease undergoing percutaneous coronary intervention(PCI).[Method]Data retrieval was made by using such databases as the Pub Med,Embase,Web of Science,Cochrane Library,Chinese CNKI Database and Wanfang Database from January 1,2000 to August 31,2017.Based on the inclusion and exclusion criteria,we collected randomized controlled trials or cohort studies that compared the efficacy and safety of dual antithrombotic therapy and triple antithrombotic therapy in patients with atrial fibrillation complicated with coronary atherosclerotic heart disease undergoing percutaneous coronary intervention(PCI).All-cause mortality,major adverse cardiovascular and cerebrovascular events(MACCE),myocardial infarction(MI),ischemic stroke,and stent thrombosis were used to assess the effectiveness of the treatment,while the major bleeding events were used to assess the safety.The pooled effects of the interventions were calculated using Odds ratio(OR)with 95% confidence intervals(95% CIs).The heterogeneity across the trials was assessed with the Q statistic and the I2 test,with P<0.1 and/or I2>50%,indicating statistically significant heterogeneity,using a random effect model for analysis.If P >0.1 and/or I2 < 50%,using a fixed effect model for analysis.Meta-analyses of this study were performed by using the Review Manager 5.3software.[Results]Thirteen studies with a total of 26,456 patients were included in this analysis,including 14,751 in the DT group(8,342 in the DAPT group and 6,407 in the OAC+SAPT group)and 7,080 in the DT group.Other 4627 cases treated with single antiplatelet or oral anticoagulant.No significant differences(P>0.05)were found between the TT group and the DT group regarding all-cause mortality(OR=1.34,95%CI:0.93-1.91),major adverse cardiovascular and cerebrovascular events(MACCE)(OR= 1.42,95 % CI : 0.96-2.10),myocardial infarction(MI)(OR=1.17,95%CI:0.84-1.61),or stent thrombosis(OR= 1.35,95%CI:0.94-1.95),and higher rates were observed for ischemic stroke(OR= 1.54,95%CI:1.32-1.80)with TT group(P < 0.05).However,the incidence of major bleeding(OR=0.64,95%CI:0.53-0.77)in TT group was significantly higher than that in the DT group(P<0.05).Meanwhile,there were no significant differences(P>0.05)between the DAPT group and OAC+SAPT group for all-cause mortality(OR=1.09,95%CI:0.93-1.27;P=0.29),ischemic stroke(OR= 0.93,95%CI:0.73-1.18;P=0.54)or major bleeding(OR= 0.94,95%CI:0.58-1.51;P=0.79).[Conclusion]In patients with atrial fibrillation complicated with coronary atherosclerotic heart disease undergoing percutaneous coronary intervention(PCI):1.Compared with TT group,DT group showed equal efficacy in terms of all-cause mortality,MACCE,MI,and stent thrombosis and significantly reduced major bleeding events.However,DT group increased the incidence of ischemic stroke.2.In the DT group subgroup analysis,compared with TT group,DAPT group or OAC+SAPT group both showed equal efficacy in terms of all-cause mortality,MACCE,MI,and stent thrombosis and significantly reduced major bleeding events.However,DT group increased the incidence of ischemic stroke.3.Compared with DAPT group,OAC+SAPT group had no statistically significant difference in all-cause mortality and ischemic stroke,and did not increase major bleeding events,showing the same efficacy and safety outcomes.