Short- and long-term efficacy and safety of triple vs. dual antithrombotic therapy in patients with drug-eluting stent implantation and an indication for oral anticoagulation: a meta-analysis

Background: The optimal anti thrombotic regimen after coronary stenting in patients taking oral anticoagulants (OACs) is still unclear. Therefore, this meta-analysis focused on the short- and long-term efficacy and safety of triple therapy (TT: OAC, aspirin, and thienopyridine) and dual therapy (DT: OAC plus single antiplatelet drug or aspirin plus thienopyridine). Methods: We searched PubMed, Embase, the Cochrane Library, Wangfang database, and Google Scholar up to December 1, 2015 (January 1, 2000 - December 2015), from randomized and nonrandomized studies comparing TT and DT in patients with OACs undergoing drug-eluting stent (DES) implantation. Major adverse cardiac and cerebrovascular events (MACCE) were the main outcome. Safety outcome was major bleeding (MB). Results: Of 964 publications identified, 1 randomized study and 27 nonrandomized studies of 31,346 patients were included. Overall, TT and OAC plus clopidogrel were associated with a lower risk of MACCE, stroke, MI, and all-cause mortality compared with dual antiplatelet therapy or OAC plus aspirin. Additionally, short-term use of triple antithrombotic regimen with OAC, aspirin, and clopidogrel is associated with equivalent risk of major bleeding and decreased rate of MACCE. Long-term use of OAC plus clopidogrel after TT was associated with equal or better benefit and safety outcomes. Conclusion: For patients on OAC after coronary stenting, triple therapy (OAC, aspirin, clopidogrel) should be considered in the short term, followed by more long-term therapy with OAC plus clopidogrel. More randomized studies are needed to confirm these findings.