Secondary Logo

Omission of aspirin in patients taking oral anticoagulation after percutaneous coronary intervention

a systematic review and meta-analysis

Zhang, Jiana,b,c,d,e; Wang, Zhenga,b,c,d,e; Sang, Wentaoa,b,c,d,e; Wei, Maozenga,b,c,d,e; Xu, Fenga,b,c,d,e; Chen, Yuguoa,b,c,d,e

doi: 10.1097/MCA.0000000000000698
Antiplatelet Therapy in PCI
Free
SDC

Background There is no consensus on optimal antiplatelet and anticoagulation therapy after coronary stenting.

Methods We identified randomized controlled trials (RCTs) published in PubMed, Cochrane Library, and Embase using the following keywords: ‘antiplatelet’, ‘dual therapy’, ‘triple therapy’, ‘antithrombosis’, ‘indication for anticoagulation’, ‘percutaneous coronary intervention’, and ‘RCTs’. Primary safety end points were relative bleeding events, and secondary efficacy end points were major adverse cardiovascular events including stent thrombosis, death, myocardial infarction, and stroke.

Results We identified three RCTs including 5387 patients, of whom 2719 (50.5%) received dual therapy (DT) and 2668 (49.5%) received triple therapy. Relative to triple therapy, DT was associated with lower Thrombolysis in Myocardial Infarction major bleeding [risk ratio (RR): 0.58; 95% confidence interval (CI): 0.42–0.82], Thrombolysis in Myocardial Infarction minor bleeding (RR: 0.46; 95% CI: 0.34–0.62), and clinical bleeding events (RR: 0.61; 95% CI: 0.47–0.81). There was no significant difference for the secondary efficacy end point. In subgroup analyses, results were similar by sex, bleeding risk, and stent type; however, DT appeared suitable for patients aged less than 75 years but not more than or equal to 75 years, implying that there may be no ideal therapy for patients older than 75 years to balance the risk of ischemia and bleeding at the same time.

Conclusion Among patients with an indication for oral anticoagulation after percutaneous coronary intervention, DT appears to be the optimal strategy.

aDepartment of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University

bClinical Research Center for Emergency and Critical Care Medicine of Shandong Province, Institute of Emergency and Critical Care Medicine

cKey Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province

dThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences

eThe State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Shandong University, Jinan, People’s Republic of China

Correspondence to Feng Xu, MD, PhD, Qilu Hospital, Shandong University, No. 107, Wen Hua Xi Road, Jinan, Shandong 250012, People’s Republic of China Tel: +86 531 8216 9325; fax: +86 531 8692 7544; e-mail: xufengsdu@126.com

Received August 21, 2018

Received in revised form November 26, 2018

Accepted December 8, 2018

Back to Top | Article Outline

Introduction

Approximately 6–8% of the patients undergoing percutaneous coronary intervention (PCI) have an indication for long-term oral anticoagulation (OAC) owing to various conditions, such as atrial fibrillation (AF), mechanical heart valves, or venous thromboembolism. OAC and antiplatelet therapy is recommended, but with low level of evidence 1–4.

It is difficult to balance bleeding risk and thromboembolism risk among patients with an indication for OAC after PCI. In some observational studies and meta-analyses, triple therapy (TT) was complicated by high risk of bleeding despite being associated with significant lower risk of all-cause mortality, stroke, and stent thrombosis (ST) in patients with AF after PCI compared with double antiplatelet therapy (DAPT) or with dual therapy (DT) 5–8. In other observational studies, no concomitant benefit was apparent for the composite efficacy end point of cardiovascular death, myocardial infarction, or stroke, when comparing TT with DT or DAPT 7,9–12. Furthermore, results from two recent meta-analyses preferred DT to TT 13,14, but there is more information we can get from the extant data. The present systematic review and meta-analysis of randomized controlled trials aimed to determine if aspirin is still needed to improve clinical outcomes in patients with an indication for OAC after coronary stenting.

Back to Top | Article Outline

Methods

We identified RCTs published in PubMed, Cochrane Library, and Embase using the following keywords: ‘antiplatelet’, ‘dual therapy’, ‘triple therapy’, ‘antithrombosis’, ‘indication for anticoagulation’, ‘percutaneous coronary intervention (PCI)’, and ‘randomized controlled trials’. We limited our search criteria to include studies published in the English language and those involving humans. We identified additional studies by searching Clinicaltrials.gov and by hand searching references cited in relevant publications.

Back to Top | Article Outline

Data sources and study search strategy

We included studies that (a) were randomized controlled, (b) enrolled patients with long-term indications for OAC after PCI, (c) compared the outcomes of DT versus TT, and (d) reported long-term rates of bleeding and of major adverse cardiac events, ST, death, myocardial infarction, and stroke.

We excluded studies that (a) were not randomized controlled, (b) did not involve DT and TT group in the same study, and (c) were not designed for humans.

Back to Top | Article Outline

Study selection

Our initial search yielded 163 citations, and their abstracts were reviewed for eligibility. A total of 10 full-text articles were read, and only three clinical trials were included in this meta-analysis (Fig 1) 15–17.

Fig. 1

Fig. 1

Back to Top | Article Outline

Data extraction

Data were abstracted by two reviewers (J.Z. and F.X.) using standardized data extraction forms. Discrepancies were resolved by consensus. Abstracted information included study design, time frame, key patient and procedural characteristics, and relevant outcomes.

Back to Top | Article Outline

Outcomes

The primary safety end points for this meta-analysis were Thrombolysis in Myocardial Infarction (TIMI) major bleeding, TIMI minor bleeding, TIMI major or minor bleeding, and clinical bleeding events. Secondary efficacy end points were MACE, ST, death, myocardial infarction, and stroke.

Back to Top | Article Outline

Methodological quality

Study selection, data collection, analysis, and reporting of the results were performed on the basis of the Cochrane Handbook for Systematic Reviews of Interventions published by The Cochrane Collaboration 18. Heterogeneity across trials was assessed using the Cochrane Q-statistic (P<0.1 was considered significant) and I 2-statistic. I 2 describes the percentage of total variation across studies that is owing to heterogeneity rather than chance. A value of 0% indicates no heterogeneity, and larger values indicate increased heterogeneity. The methodological quality of the randomized trials was assessed by Cochrane’s Collaboration tool for assessing risk of bias. For each trial, bias was assessed qualitatively as low risk, intermediate risk, or high risk of bias by independent investigators (Supplementary Fig. 1, Supplemental digital content 1, http://links.lww.com/MCA/A227). Publication bias was visually estimated by assessing funnel plots.

We calculated weighted risk ratios (RRs) and 95% confidence intervals (CIs) for categorical variables. The fixed model was chosen when there was no heterogeneity among trials, and the random model when there was heterogeneity. All analyses were performed using RevMan software [Review Manager (RevMan) (Computer program), version 5.3, The Cochrane Collaboration, 2014; The Nordic Cochrane Centre, Copenhagen, Denmark].

Back to Top | Article Outline

Patient and public involvement

No patients or public were involved in this study.

Back to Top | Article Outline

Results

Study and patient characteristics

The characteristics of the included studies are displayed in Table 1. The funnel plots were not suggestive of a publication bias. DT represents one P2Y12 inhibitor as the antiplatelet drug plus OAC, and TT represents DAPT plus OAC.

Table 1

Table 1

The present analysis included 5387 patients, of whom 2719 (50.5%) received DT and 2668 (49.5%) received TT. The mean age of the participants was 70.4±8.7 years, 76.1% were men, 32.6% had diabetes, 25.5% had history of MI, 95.8% had AF, and 74.4% had acute coronary syndrome.

Back to Top | Article Outline

Primary safety end points

Of the 5387 patients included in this meta-analysis, 1142 (21.2%) experienced clinical bleeding events. DT was associated with reduced bleeding risk relative to TT (RR: 0.61; 95% CI: 0.47–0.81, P<0.001, I 2=82%) (Fig 2). The bleeding benefit was observed in patients treated with DT compared with TT, regardless of whether it was TIMI major bleeding, TIMI minor bleeding, or TIMI major or minor bleeding (RR: 0.58; 95% CI: 0.42–0.82; P=0.002; I 2=27%, RR: 0.46; 95% CI: 0.34–0.62; P<0.001; I 2=0%, RR: 0.52; 95% CI: 0.38–0.73; P<0.001; I 2=54%, respectively) (Figs 3–5).

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Fig. 4

Fig. 4

Fig. 5

Fig. 5

Back to Top | Article Outline

Secondary efficacy end points

The overall number of MACE and ST during follow-up for all three RCTs was 564 (10.4%). The rates for each component of the end points did not differ significantly between DT and TT groups (P=0.59, 0.54, 0.48, 0.65, and 0.59, respectively) (Figs 6–7; Supplementary Figs 2–4, Supplemental digital content 1, http://links.lww.com/MCA/A227).

Fig. 6

Fig. 6

Fig. 7

Fig. 7

Back to Top | Article Outline

Subgroup analyses

A total of 4818 patients from two trials were included in the subgroup analyses. Compared with TT, DT reduced the risk of clinical bleeding events in men and women (RR: 0.66, 95% CI: 0.50–0.88, P=0.005; RR: 0.76; 95% CI: 0.60–0.95, P=0.02) (Supplementary Fig. 5, Supplemental digital content 1, http://links.lww.com/MCA/A227), in people at least 75 years old and those less than 75 years old (RR: 0.80; 95% CI: 0.65–0.99, P=0.04; RR: 0.67; 95% CI: 0.58–0.77, P<0.001) (Supplementary Fig. 6, Supplemental digital content 1, http://links.lww.com/MCA/A227), and in patients with bare-metal stents and in patients with drug-eluting stents (RR: 0.65; 95% CI: 0.43–0.99, P=0.05; RR: 0.69; 95% CI: 0.60–0.80, P<0.001) (Supplementary Fig. 7, Supplemental digital content 1, http://links.lww.com/MCA/A227). In terms of MACE in equivalent subgroups, analyses showed no significant difference comparing DT with TT (P=0.57, P=0.85 for male and female; P=0.12, P=0.99 for >75 years old and <75 years old; and P=0.59, P=0.75 for bare-metal stents and drug-eluting stents subgroup, respectively) (Supplementary Figs 8–10, Supplemental digital content 1, http://links.lww.com/MCA/A227). However, based on the age subgroup results, DT appears suitable for patients aged less than 75 but not more than or equal to 75 years.

Back to Top | Article Outline

Discussion

In the present systematic review and meta-analysis, DT versus TT in patients with an indication for OACs after PCI was associated with a 42% reduction in TIMI major bleeding, a 54% reduction in TIMI minor bleeding, and a 39% reduction in clinical bleeding events, with no increase in the risk of MACE or ST.

The association between DT and lower risk for subsequent bleeding events may be causal. The omission of aspirin significantly reduces bleeding risk because of gastric mucosa protection and no over-inhibition of platelet function. A study showed that risk of receiving excess dosing of antiplatelet and antithrombin agents in ∼42% patients with non-ST-segment elevation acute coronary syndromes was associated with older age, female sex, renal insufficiency, low body weight, diabetes, and congestive heart failure 19.

The 2014 ESC/EACTS Guidelines on myocardial revascularization recommended that TT be used in patients with definite indication for OAC. TT should be used for at least 6 months followed by DT for up to 12 months when patients are at low bleeding risk (HAS-BLED≤2) and for 1 month followed by DT when patients are at high bleeding risk (HAS-BLED≥3). The 2017 ESC/EACTS guidelines on dual antiplatelet therapy in coronary artery disease recommended that TT be used for 6 months followed by DT consisting of OAC plus aspirin or clopidogrel for up to 12 months in patients with indications for OAC after PCI considering high ischemic risk. In consideration of high bleeding risk, TT can be used for 1 month followed by DT for up to 12 months or initiating DT for 12 months. However, as shown in this meta-analysis, despite the bleeding risk, DT could be used as initiating therapy, and compared with TT, DT reduced bleeding risk with no increase in ischemic events.

Because most bleeding events occur within the first month during antiplatelet and anticoagulation management, the strategies recommended by ESC guidelines might not bring many benefits to patients in terms of prevention of bleeding events 20. As shown in ISAR-TRIPLE trial, 6 weeks versus 6 months of triple therapy did not provide additional benefit to patients with respect to TIMI major bleeding. Based on the present meta-analysis, one could posit that regardless of ischemic or bleeding risk level, DT consisting of dabigatran plus clopidogrel or other P2Y12 inhibitor might be an option as initiating therapy for at least 6 months in patients with an indication for OAC after PCI. However, the omission of aspirin may increase the risk of ST by 25%. Furthermore, none of the included three RCTs had enough power to examine ischemic risks including ST and cardiovascular-related death, which would have required inclusion of at least 14 000 patients 21.

New-generation drug-eluting stents (DES) reduce the rate of revascularization by 10–20% and the risk of death, MI or ST, as compared with early DES and bare-metal stents, and the rate of ST by ∼50%, especially in late antithrombotic phase, as compared with early DES 22,23. The three DT versus TT RCTs and meta-analysis thereof favor DT over TT, which differs from early studies, may be partly owing to the extensive use of new-generation DES.

Currently, vitamin K antagonist (VKA) has been widely used for anticoagulation in patients with indication for anticoagulation (AF mostly), and VKA is superior to aspirin or DAPT. For patients after PCI, DAPT is superior to OAC. The use of DAPT after PCI significantly reduces acute or late thrombosis events and mortality rates. VKA use in patients with AF reduces stroke risk by two-third and mortality rate by one-fourth. So far, there is insufficient evidence on optimal antithrombotic strategy to balance bleeding risk and ischemic risk in patients with PCI with an indication for OAC using antiplatelet drugs concomitantly. At first, combined use of DAPT and OAC was recommended by expert consensus 24,25, albeit without strong supporting evidence. The subsequent WOEST clinical trial in 2013 concluded that DT significantly reduced clinical bleeding events in patients at the first year as compared with TT, with no increased ischemic risk. However, there was no significant difference in major bleeding between DT and TT. Because the trial was not powered to test ischemic risk, and other antiplatelet agents and novel OACs were not included, DT did not gain popularity. In real world, the usage of DT is rare, and most doctors prefer TT as recommended by experts. A data analysis from 1269 patients with history of AF treated with PCI at a tertiary care hospital in New York City from 2010 to 2015 showed that 55% of patients were treated with TT, 37% with DAPT, only 12% with DT 26. Recently, several observational studies and pooled analysis of observational studies showed that TT significantly reduced the risk of all-cause mortality, stroke, and thrombosis, with significant increase in bleeding risk, whereas other observational studies showed that TT was associated with a significant increase in bleeding risk with no benefit on cardiovascular death, myocardial infarction, and stroke risk.

With the extensive use of novel OAC, researchers changed VKA to rivaroxaban for new DT in PIONEER AF-PCI trial in 2016. Compared with TT, DT reduced clinical bleeding events by 41%, without significant difference in TIMI major bleeding, TIMI minor bleeding, and MACE. The latter trial differs from the present meta-analysis in terms of TIMI major bleeding and TIMI minor bleeding in that it used rivaroxaban in DT, and rivaroxaban causes more bleeding than dabigatran, as shown by previous studies.

RE-DUAL PCI conducted in 2017 showed that DT consisting of 150 mg dabigatran plus P2Y12 inhibitor reduced TIMI major bleeding by 49% and TIMI major or minor bleeding by 47% when compared with TT, with no increase in ischemic risk; therefore, it is consistent with the results of the present meta-analysis. Compared with PIONEER AF-PCI trial, RE-DUAL PCI trial showed that DT containing dabigatran is safer than DT containing rivaroxaban.

Two meta-analyses were published recently with important design and conclusion differences with ours 13,14. In terms of meta-analysis design, we excluded the ISAR-TRIPLE trial because it evaluated the duration of clopidogrel in TT and not DT versus TT, with patients on long-term aspirin and OAC randomized to 6-week clopidogrel group or 6-month clopidogrel group, and we included 2.5 mg rivaroxaban plus DAPT group in PIONEER AF-PCI trial as TT. There was a discrepancy in the published meta-analysis written by Cavallari et al. 13 in the data from RE-DUAL PCI in terms of TIMI minor bleeding: the number of minor bleeding events should be 26 in DT and 32 in TT, not 56 and 69. They regarded the total number of both minor and major bleeding events as the number of minor bleeding events 17. The aforementioned differences may significantly affect the results of the meta-analysis. As for the conclusion of the meta-analysis, our data suggest that the optimal combination of DT appears to be P2Y12 inhibitor plus 150 mg dose of dabigatran; 110 mg dose of dabigatran may increase the risk of ST by 28%, but more data are warranted. We also conducted subgroup analyses in our meta-analysis. The use of DT reduced the risk of bleeding in men and women by 34 and 24%, respectively, with no increase in the risk of MACE. The use of DT in patients aged more than 75 years reduced bleeding risk by 20% while increasing MACE by 32%, suggesting that there might be no optimal way to concurrently reduce bleeding risk and ischemic risk in this age group. In patients aged less than 75 years, DT reduced bleeding risk by 33%, with no increase in the risk of MACE, rendering it suitable for this age group. In our data, DT also reduced the risk of clinical bleeding events by 45% in patients with HAS-BLED up to 2 and by 47% in those with HAS-BLED more than 2, with no increase in MACE. DT might therefore be beneficial to patients with low bleeding risk, which differs from the current ESC guidelines recommendation for DT as an option only in patients with high bleeding risk after doctors’ prudent consideration and TT in patients even with low bleeding risk.

Back to Top | Article Outline

Limitations

There are limitations to our meta-analysis. First, evidence remains insufficient in terms of efficacy to support DT. Second, four relevant DT versus TT RCTs are ongoing which might better inform optimal antiplatelet and anticoagulation therapy in patients with AF after PCI: ENTRUST-AF-PCI (1500 patients), P2Y12 inhibitor plus edoxaban versus P2Y12 inhibitor and aspirin plus VKA; AUGUSTUS (4600 patients), P2Y12 inhibitor plus apixaban or VKA versus P2Y12 inhibitor and aspirin plus apixaban or VKA; MANJUSRI (296 patients), ticagrelor plus warfarin versus clopidogrel and aspirin plus warfarin; and RT-AF (420 patients), rivaroxaban plus ticagrelor versus clopidogrel and aspirin plus warfarin.

Back to Top | Article Outline

Conclusion

Among patients with an indication for OAC after PCI, DT may be the optimal antiplatelet and anticoagulation therapy.

Back to Top | Article Outline

Acknowledgements

This study was supported by Taishan Scholar Program of Shandong Province (tsqn20161065, ts20130911), National Key Research and Development Program (2017YFC0908700, 2017YFC0908703), the grants from Department of Science and Technology of Shandong Province (2017G006013, 2016GSF201235, 2016ZDJS07A14, 2018GSF118003), Evaluation and Management of Patients with Acute Chest Pain in China (EMPACT)(201525), the National Natural Science Foundation of China (81571934, 81570401, 81601717), Natural Science Foundation of Shandong Province (BS2014YY032), Science Foundation of Qilu Hospital of Shandong University (2016QLQN02).

Back to Top | Article Outline

Conflicts of interest

There are no conflicts of interest.

Back to Top | Article Outline

References

1. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018; 39:119–177.
2. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893–2962.
3. Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2018; 39:213–260.
4. Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541–2619.
5. Barbieri L, Verdoia M, Schaffer A, Suryapranata H, De Luca G. Risk and benefits of triple therapy in patients undergoing coronary stent implantation requiring oral anticoagulation: a meta-analysis of 16 studies. Cardiovasc Drugs Ther 2016; 30:611–622.
6. Chaudhary N, Bundhun PK, Yan H. Comparing the clinical outcomes in patients with atrial fibrillation receiving dual antiplatelet therapy and patients receiving an addition of an anticoagulant after coronary stent implantation: A systematic review and meta-analysis of observational studies. Medicine 2016; 95:e5581.
7. Mennuni MG, Halperin JL, Bansilal S, Schoos MM, Theodoropoulos KN, Meelu OA, et al. Balancing the risk of bleeding and stroke in patients with atrial fibrillation after percutaneous coronary intervention (from the AVIATOR Registry). Am J Cardiol 2015; 116:37–42.
8. Zhao HJ, Zheng ZT, Wang ZH, Li SH, Zhang Y, Zhong M, et al. ‘Triple therapy’ rather than ‘triple threat’: a meta-analysis of the two antithrombotic regimens after stent implantation in patients receiving long-term oral anticoagulant treatment. Chest 2011; 139:260–270.
9. Bavishi C, Koulova A, Bangalore S, Sawant A, Chatterjee S, Ather S, et al. Evaluation of the efficacy and safety of dual antiplatelet therapy with or without warfarin in patients with a clinical indication for DAPT and chronic anticoagulation: A meta-analysis of observational studies. Catheter Cardiovasc Interv 2016; 88:E12–E22.
10. D’Ascenzo F, Taha S, Moretti C, Omed P, Grossomarra W, Persson J, et al. Meta-analysis of randomized controlled trials and adjusted observational results of use of clopidogrel, aspirin, and oral anticoagulants in patients undergoing percutaneous coronary intervention. Am J Cardiol 2015; 115:1185–1193.
11. Gao XF, Chen Y, Fan ZG, Jiang XM, Wang ZM, Li B, et al. Antithrombotic Regimens for patients taking oral anticoagulation after coronary intervention: a meta-analysis of 16 clinical trials and 9,185 patients. Clin Cardiol 2015; 38:499–509.
12. Lamberts M, Olesen JB, Ruwald MH, Hansen CM, Karasoy D, Kristensen SL, et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study. Circulation 2012; 126:1185–1193.
13. Cavallari I, Patti G. Meta-analysis comparing the safety and efficacy of dual versus triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Am J Cardiol 2018; 121:718–724.
14. Golwala HB, Cannon CP, Steg PG, Doros G, Qamar A, Ellis SG, et al. Safety and efficacy of dual vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of randomized clinical trials. Eur Heart J 2018; 39:1726–1735a.
15. Dewilde WJ, Oirbans T, Verheugt FW, Kelder JC, De Smet BJ, Herrman JP, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381:1107–1115.
16. Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. N Engl J Med 2016; 375:2423–2434.
17. Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, et al. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med 2017; 377:1513–1524.
18. Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available at: www.cochrane-handbook.org. [Accessed 8 July 2018].
19. Alexander KP, Chen AY, Roe MT, Newby LK, Gibson CM, Allen-LaPointe NM, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA 2005; 294:3108–3116.
20. Pareek M, Bhatt DL, ten Berg JM, Kristensen SD, Grove EL. Antithrombotic strategies for preventing long-term major adverse cardiovascular events in patients with non-valvular atrial fibrillation who undergo percutaneous coronary intervention. Expert Opin Pharmacother 2017; 18:875–883.
21. Jolly SS, Natarajan MK. Atrial fibrillation and PCI – do we still need aspirin? N Engl J Med 2016; 22:2490–2492.
22. Angiolillo DJ, Goodman SG, Bhatt DL, Eikelboom JW, Price MJ, Moliterno DJ, et al. Antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a North American perspective-2016 update. Circ Cardiovasc Interv 2016; pii:e004395.
23. Baber U, Mehran R, Sharma SK, Brar S, Yu J, Suh JW, et al. Impact of the everolimus-eluting stent on stent thrombosis: a meta-analysis of 13 randomized trials. J Am Coll Cardiol 2011; 58:1569–1577.
24. Faxon DP, Eikelboom JW, Berger PB, Holmes DR, Bhatt DL, Moliterno DJ, et al. Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective. Thromb Haemost 2011; 106:572–584.
25. Lip GY, Huber K, Andreotti F, Arnesen H, Airaksinen KJ, Cuisset T, et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/stenting. Thromb Haemost 2010; 103:13–28.
26. Faggioni M, Chandrasekhar J, Aquino M, Vogel B, Baber U, Sharma S, et al. Real world use of antithrombotic regimens after percutaneous coronary intervention in patients with atrial fibrillation. J Am Coll Cardiol 2016; 68:B91.
Keywords:

acute coronary syndrome; atrial fibrillation; hemorrhage; myocardial infarction; percutaneous coronary intervention

Supplemental Digital Content

Back to Top | Article Outline
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.