The optimal duration of triple antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention: A network meta-analysis of randomized clinical trials

Background: Triple antithrombotic therapy (TAT) consisting of anticoagulant and dual antiplatelet agents is a core treatment for prevention of ischemic events in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing post-percutaneous coronary intervention (PCI), however, due to bleeding risks, the optimal duration of TAT is unclear. Methods: We searched the database and conducted a network meta-analysis of randomized controlled trials (RCTs) to determine the optimal duration of TAT for patients with AF and ACS or undergoing PCI by comparing the probability of ischemic and bleeding outcomes for four different TAT durations. Results: After analyzing data from 12,329 patients, we determined that short-term TAT is advantageous to varying degrees for reducing bleeding events. While long-term TAT has a lower stent thrombosis risk than short -term TAT, the four strategies have comparable outcomes for major adverse cardiovascular events (MACE), stroke, all-cause death, and myocardial infarction events. Based on Surface Under the Cumulative Ranking (SUCRA) values, no treatment duration has an absolute advantage for reducing these ischemic events. Conclusion: Long-term TAT may be reasonable for patients at a high risk for stent thrombosis, but short-term TAT is associated with fewer bleeding complications, and there are no significant differences in most ischemic events across treatment durations. Overall, our results indicate that short-term TAT should be the default strategy unless there is a high risk of stent thrombosis that warrants appropriate prolongation of TAT duration.