Antithrombotic strategies in patients needing oral anticoagulation undergoing percutaneous coronary intervention: A network meta‐analysis

Background The optimal antithrombotic regimen in patients with a concomitant indication for oral anticoagulation (OAT) presenting with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) remains unclear. Objectives To perform a network meta‐analysis of all randomized controlled trials (RCTs) evaluating different antithrombotic regimens among patients with ACS or undergoing PCI requiring OAT. Methods Network meta‐analysis was performed in a frequentist framework. Antithrombotic regimens were categorized by OAC type (vitamin K antagonist‐based [VKA]; non‐VKA OAT [NOAC]) and antiplatelet agents (P2Y inhibitor only: dual therapy [DAT]; P2Y plus aspirin: triple therapy [TAT]). Safety outcomes were Thrombolysis in Myocardial Infarction (TIMI) major bleeding and intracranial hemorrhage (ICH). Efficacy outcomes were cardiovascular death, myocardial infarction, stroke and stent‐thrombosis (ST). Results Five RCTs were included, encompassing 10,797 patients (atrial fibrillation 69–100%, ACS 28–62%, PCI 77–100%). Both VKA and NOAC‐based DAT regimens reduced the occurrence of TIMI major bleeding compared to VKA TAT (VKA DAT: RR 0.62, 95% CI 0.39–0.98; NOAC DAT: RR 0.52, 95% CI 0.39–0.70). Nevertheless, only NOAC DAT significantly reduced the occurrence of ICH compared to VKA TAT (RR 0.33, 95% CI 0.17–0.64). Ischemic outcomes were similar among the four treatment regimens. However, numerical, potentially clinically important, higher ST occurrence was observed for NOAC DAT as compared to both VKA TAT (1.50, 95% confidence interval [CI] 0.96–2.33) and NOAC TAT (1.86, 95% CI 0.93–3.73). Conclusion DAT regimens present the highest safety profile among antithrombotic strategies, with a NOAC‐specific impact on ICH reduction. NOAC DAT might entail clinically important higher ST occurrence, warranting a case‐by‐case comprehensive evaluation that integrates patient‐ and procedure‐related residual ischemic risk with the patient‐specific bleeding risk.