Updated Meta-Analysis Confirms that Patients with Atrial Fibrillation Undergoing PCI Should Avoid Triple Antithrombotic Therapy with Warfarin

March 26, 2020 – DCRI faculty contributed to a recently published an updated meta-analysis that analyzed data from five clinical trials to compare four treatment options for patients with atrial fibrillation undergoing percutaneous coronary intervention.

Recent evidence suggests that a novel oral anticoagulant plus a P2Y12 inhibitor may be the best treatment pathway for patients with atrial fibrillation undergoing percutaneous coronary intervention.

DCRI faculty contributed to a meta-analysis recently published in JAMA Cardiology, which drew data from five clinical trials, including DCRI-led AUGUSTUS, to evaluate the safety and efficacy of four different antithrombotic regimens. The primary safety endpoint was major bleeding, while the primary efficacy endpoint was major adverse cardiovascular events as defined by each trial.

The analysis of 11,532 participants revealed the following findings:

  • Treatment with a Vitamin K antagonist (VKA) and dual antiplatelet therapy, which combines aspirin with an ADP receptor antagonist, resulted in the highest rates of bleeding.
  • Treatment with a non-vitamin K oral anticoagulant (NOAC) and a P2Y12 inhibitor was the most effective in reducing bleeding complications, including intracranial bleeding.

Renato Lopes, MD, PhD“The findings from this updated analysis confirm what we found in our prior study and AUGUSTUS by suggesting a clear benefit of reduced bleeding for patients who discontinue using aspirin,” said the DCRI’s Renato Lopes, MD, PhD, lead author for the updated meta-analysis and principal investigator for AUGUSTUS. “Of course, these patients are very high risk, and in treating them, we have to worry about ischemic events as well as bleeding. However, when we combined AUGUSTUS data with data from other pivotal studies in the field, we saw no significant difference in antithrombotic effectiveness among different therapies, which mitigates the risk of discontinuing aspirin. A major lesson learned, which is confirmed by our comprehensive meta-analysis, is that less is more. Using fewer antithrombotic agents, discontinuing aspirin by the time of hospital discharge, and using a NOAC instead of VKA seems to be the best route that gives physicians the sweet spot with the greatest reduction in ischemic events and a minimal risk of bleeding.”

The DCRI’s Hwanhee Hong, PhD; Christopher Granger, MD; and John Alexander, MD, MHS, contributed to this analysis. The DCRI’s Jianghao Li, MS, provided statistical support.