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Dual versus triple antithrombotic therapy after percutaneous coronary intervention or acute coronary syndrome in patients with indication for anticoagulation

an updated meta-analysis

Shin, Doosupa; Mohanty, Bibhu D.b; Lee, Eun Sunc

doi: 10.1097/MCA.0000000000000660
Anti-platelet therapy in CAD

Background For patients who have an indication for anticoagulation, it is controversial whether dual therapy with an oral anticoagulant and single antiplatelet agent can be used after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) instead of triple therapy with an oral anticoagulant and dual antiplatelet therapy.

Participants and methods Twelve observational studies and four clinical trials were identified from three electronic databases from their inception to December, 2017. Pooled estimates were calculated using a random-effects model for meta-analysis.

Results Compared with the triple therapy, dual therapy was associated with significantly lower risk of major bleeding [relative risk (RR), 0.63; 95% confidence interval (CI), 0.50–0.80] without statistically significant increase in major adverse cardiac events (RR, 1.04; 95% CI, 0.84–1.29), all-cause death (RR, 1.15; 95% CI, 0.77–1.71), cardiac death (RR, 1.04; 95% CI, 0.67–1.61), myocardial infarction (RR, 1.25; 95% CI, 0.98–1.59), stroke (RR, 1.27; 95% CI, 0.79–2.06), stent thrombosis (RR, 1.52; 95% CI, 0.96–2.41), and repeat revascularization (RR, 1.15; 95% CI, 0.87–1.52). Although risks of myocardial infarction and stent thrombosis were marginally higher in the dual therapy group, this trend was attenuated after excluding studies that exclusively included patients undergoing PCI for ACS, but not stable coronary artery disease.

Conclusion Dual therapy may be a reasonable alternative to triple therapy after PCI in patients with indication for chronic anticoagulation. However, further studies are needed to investigate efficacy of dual therapy, especially in the patients with higher ischemic risk, such as in ACS.

aDepartment of Internal Medicine

bDepartment of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida

cDepartment of Internal Medicine, Weiss Memorial Hospital, Chicago, Illinois, USA

Correspondence to Doosup Shin, MD, Department of Internal Medicine, University of South Florida Morsani College of Medicine, 17 Davis Blvd., Suite 308, Tampa, FL 33606, USA Tel: +1 813 259 0875; fax: +1 813 259 0697; e-mails:,

Received June 8, 2018

Received in revised form June 29, 2018

Accepted August 7, 2018

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