Background

The optimal antithrombotic therapy for atrial fibrillation (AF) patients undergoing coronary stenting is unknown. The present meta-analysis sought to investigate the efficacy and safety of triple therapy (TT; warfarin, clopidogrel and aspirin) vs dual antiplatelet therapy (DAPT; clopidogrel plus aspirin) in those patients.

Methods

PubMed and Cochrane Library were searched for studies enrolling AF patients undergoing coronary stenting on TT and DAPT up to September 2016, and fourteen studies were included. Efficacy outcomes included ischemic stroke, stent thrombosis, major adverse cardiovascular event (MACE), all-cause mortality and myocardial infarction (MI); safety outcome was major bleeding. We conducted meta-analysis and used odds ratio (OR) with 95% confidence intervals (CI) to compare TT and DAPT. Meta-regression, sensitivity and subgroup analysis were taken to investigate the source of heterogeneity in the outcome of major bleeding.

Results

14 eligible observational studies with 11,697 subjects were identified. Compared with DAPT, TT had decreased the risk of ischemic stroke [OR = 0.74, 95% CI (0.59, 0.93), P = 0.009] and stent thrombosis [OR = 0.40, 95% CI (0.18, 0.93), P = 0.033]. While, there was an increased risk of major bleeding [OR = 1.55, 95% CI (1.16, 2.09), P = 0.004] associated with TT. The risk of MACE, all-cause mortality and MI had no significant statistical difference between TT and DAPT. Furthermore, the results of univariate and multivariate meta-regression analysis implicated that there were no obvious correlations between certain baseline characteristics (age, gender, race, hypertension, study design) and risk of major bleeding. Also of major bleeding, the findings of sensitivity analysis were generally robust, and a prespecified subgroup analysis of race demonstrated that the source of heterogeneity might attribute to Asian studies mostly.

Conclusions

TT reduced the risk of ischemic stroke and stent thrombosis with an acceptable major bleeding risk compared with DAPT, and TT was considered as a valid alternative in AF patients undergoing coronary stenting. Further prospective randomized trials are needed to ensure the reliability of these data and find the optimal therapeutic strategy in this setting of patients.

中文翻译：

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三联疗法与双重抗血小板疗法在房颤患者冠状动脉支架置入术中的疗效和安全性：一项荟萃分析

背景

对于进行冠状动脉支架置入术的房颤（AF）患者的最佳抗血栓治疗尚不清楚。本荟萃分析旨在研究三联疗法（TT；华法林，氯吡格雷和阿司匹林）与双重抗血小板疗法（DAPT；氯吡格雷加阿司匹林）在这些患者中的疗效和安全性。

方法

搜索PubMed和Cochrane Library进行的研究，研究纳入了截至2016年9月在TT和DAPT上接受冠状动脉支架置入术的AF患者，其中包括14项研究。疗效结果包括缺血性中风，支架血栓形成，重大心血管不良事件（MACE），全因死亡率和心肌梗塞（MI）；安全性结果为大出血。我们进行了荟萃分析，并使用具有95％置信区间（CI）的优势比（OR）来比较TT和DAPT。采用Meta回归，敏感性和亚组分析来研究大出血结局中异质性的来源。

结果

确定了11 697名受试者的14项符合条件的观察性研究。与DAPT相比，TT降低了缺血性卒中的风险[OR = 0.74，95％CI（0.59，0.93），P = 0.009]和支架内血栓形成的风险[OR = 0.40，95％CI（0.18，0.93），P = 0.033 ]。同时，与TT相关的大出血风险增加[OR = 1.55，95％CI（1.16，2.09），P = 0.004]。TT和DAPT之间的MACE风险，全因死亡率和MI均无显着统计学差异。此外，单变量和多元荟萃分析的结果表明，某些基线特征（年龄，性别，种族，高血压，研究设计）与大出血风险之间没有明显的相关性。对于大出血，敏感性分析的结果通常也很可靠，

结论

与DAPT相比，TT降低了缺血性中风和支架血栓形成的风险，并具有可接受的主要出血风险，TT被认为是接受冠状动脉支架置入术的AF患者的有效替代药物。需要进一步的前瞻性随机试验，以确保这些数据的可靠性，并在这种情况下找到最佳的治疗策略。