Antithrombotic therapy strategies for atrial fibrillation patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis

<div><p>Objective</p><p>The aim of this systematic review and network meta-analysis was to evaluate the comparative efficacy and safety of antiplatelet agents, vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).</p><p>Methods</p><p>PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify clinical trials comparing antiplatelet drugs with VKA and NOACs or their combination in AF patients undergoing PCI with a mean/median follow-up of at least 12 months. A network meta-analysis was conducted to directly and indirectly compare the efficacy and safety of competitive antithrombotic regimens with a Bayesian random-effects model. Results were presented as relative risks (RRs) and 95% confidence intervals (CIs).</p><p>Results</p><p>A total of 15 studies enrolling 13,104 patients were included. Among 5 regimens, rivaroxaban 15 mg daily plus P2Y₁₂ inhibitor treatment demonstrated significant superiority over dual- and triple-antiplatelet therapies (DAPT, TT) in reducing thromboembolic events (0.64 [0.38, 0.95] and 0.68 [0.43, 0.98], respectively) but showed the maximum possibility of major bleeding risk, while VKA plus single antiplatelet therapy (SAPT) seemed the safest. Significantly less risk of major bleeding was seen in DAPT group than that in TT group (0.63 [0.39, 0.99]).</p><p>Conclusions</p><p>The present study suggests that combination of VKA and SAPT is the best choice for AF patients undergoing PCI considering both efficacy and safety. Rivaroxaban 2.5 mg twice daily plus DAPT treatment owns the highest probability to be the optimal alternative to VKA plus SAPT for these patients.</p></div

NMA results of MACCEs risk for all treatments relative to each other under the consistency model.

<p>NMA results of MACCEs risk for all treatments relative to each other under the consistency model.</p

NMA results of major bleeding risk for all treatments relative to each other under the consistency model.

<p>NMA results of major bleeding risk for all treatments relative to each other under the consistency model.</p

The distribution of MACCEs probabilities of 5 treatments being ranked at possible positions.

<p>MACCEs, main adverse cardiac and cerebrovascular events; DAPT, dual-antiplatelet therapy; Riva15 + P2Y₁₂, rivaroxaban 15 mg/d plus P2Y₁₂ inhibitor; Riva2.5 + P2Y₁₂, rivaroxaban 2.5 mg bid plus P2Y₁₂ inhibitor; TT, triple-antiplatelet therapy; VKA, vitamin K antagonist; SAPT, single antiplatelet therapy.</p

Main characteristics of studies and patients included in the network meta-analysis.

<p>Main characteristics of studies and patients included in the network meta-analysis.</p

Network diagram of treatment comparisons for MACCEs and major bleeding of competitive antithrombotic regimens.

<p>MACCEs, main adverse cardiac and cerebrovascular events; DAPT, dual-antiplatelet therapy; TT, triple-antiplatelet therapy; VKA, vitamin K antagonist; SAPT, single antiplatelet therapy; Riva15 + P2Y₁₂, rivaroxaban 15 mg/d plus P2Y₁₂ inhibitor; Riva2.5 + P2Y₁₂, rivaroxaban 2.5 mg bid plus P2Y₁₂ inhibitor. The size of each node is proportional to the overall sample size of the corresponding therapy. Each line represents the direct comparison between two treatments, and the corresponding width is proportional to the number of trials. Number next to the line indicates the specific number of studies.</p

The distribution of major bleeding probabilities of 5 treatments being ranked at possible positions.

<p>DAPT, dual-antiplatelet therapy; Riva15 + P2Y₁₂, rivaroxaban 15 mg/d plus P2Y₁₂ inhibitor; Riva2.5 + P2Y₁₂, rivaroxaban 2.5 mg bid plus P2Y₁₂ inhibitor; TT, triple-antiplatelet therapy; VKA, vitamin K antagonist; SAPT, single antiplatelet therapy.</p

Forest plot of sensitivity for drug resistance to ethambutol.

<p>A. Sensitivity; B. Specificity.</p

Summary of included studies.

<p>Abbreviations: TR = true resistance; FR = false resistance; FS = false susceptibility; TS = true susceptibility; FLQs = fluoroquinolones; AM = amikacin; CAP = capreomycin; KAN = Kanamycin; EMB = ethambutol; NA = not available.</p

Summary receiver operating characteristic (SROC) curve for drug resistance to fluoroquinolones, amikacin, capreomycin, kanamycin, and ethambutol.

<p>A. Summary receiver operating characteristic (SROC) curve for drug resistance to fluoroquinolones B Summary receiver operating characteristic (SROC) curve for drug resistance to amikacin C. Summary receiver operating characteristic (SROC) curve for drug resistance to capreomycin D. Summary receiver operating characteristic (SROC) curve for drug resistance to kanamycin E. Summary receiver operating characteristic (SROC) curve for drug resistance to ethambutol.</p