The Comparative Efficacy And Safety Of Dual Antithrombotic Regimens In Patients With Atrial Fibrillation(AF) Undergoing PCI

Background:The balance between thromboembolic and hemorrhagic complications in treating Atrial fibrillation（AF）patients undergoing percutaneous coronary intervention（PCI）is a critical issue in clinical practice.Though with guidelines and expert consensuses recommending dual antithrombotic therapy（DAT）strategy,the optimal combination of dual antithrombotic drugs needs further research.Objective:To assess whether a traditional DAT（containing vitamin K antagonist）is truly distinct from novel DAT（containing novel oral anticoagulant）and whether a standard dose or low dose novel DAT is different at efficacy and safety outcomes in AF patients undergoing PCI.Methods:A network meta-analysis was conducted by searching PubMed,Embase,Cochrane Library,and Clinicaltrials.gov for randomized controlled trialsdifferent antithrombotic regimens in AF patients undergoing PCI from inception to April,2019.The trials containing DAT arms were extracted into analysis.The primary efficacy endpoint was assessed by Major Adverse Cardiovascular Event（MACE）and the primary safety outcomes were assessed by Thrombolysis in Myocardial Infarction（TIMI）major or minor bleeding and ISTH major or CRNM bleeding,respectively.The secondary endpoints like all-causemortality（AM）,stroke,myocardialinfarction（MI）,stent thrombosis（ST）,intracranial bleeding（IB）were also taken into account.All the data were calculated using Aggregate Data Drug Information System（ADDIS）v2.0 online.Results:A total of 5 trials with 9931 patients involving 8 types of interventions were included in this study.In traditional DAT versus novel DAT,the results showed that novel DAT（NOAC+MAPT）was able to reduce ISTH defined major bleeding or clinically relevant nonmajor bleeding event（ISTH）（RR 0.585,95%CI 0.363-0.945）,TIMI major bleeding or minor bleeding event（TIMI）（RR 0.511,95%CI 0.303-0.876）and intracranial bleeding event（IB）（RR 0.186,95%CI 0.041-0.639）in the comparison with Triple Therapy（TT）group.But there was no statistically significant difference in bleeding risks between traditional DAT（VKA+MAPT）and TT group.Major adverse cardiovascular event（MACE）,all-cause mortality（AM）,myocardial infarction（MI）,Stroke and stent thrombosis（ST）were observed with no statistical differences among three groups.In comparison between novel DAT at different doses,traditional DAT（VKA+MAPT）reduced Stent thrombosis（ST）compared with standard dose novel DAT（NOAC（L）+P2Y12）（RR 0.085,95%CI 0.003-0.864）.There was no statistically significant differences between NOAC（S）+P2Y12 group and VKA+MAPT group at major adverse cardiovascular event（MACE）,TIMI Major or minor bleeding event（TIMI）,ISTH major bleeding or clinically relevant non-major bleeding event（ISTH）,all-cause mortality（AM）,myocardial infarction（MI）,stroke,intracranial hemorrhage（IB）and stent thrombosis（ST）.Conclusion:For AF patients undergoing PCI required anticoagulation,the standard dose novel oral anticoagulant combined with a P₂Y₁₂2 receptor antagonist（NOAC（S）+P2Y12）may be the best option in dual antithrombotic strategy.