Is Double or Triple Antithrombotic Therapy Safer in CAD and AF?

There are no significant differences between double antithrombotic therapy (DATT) and triple antithrombotic therapy (TATT) regarding the outcomes of mortality, stroke, nonfatal myocardial infarction (MI), and stent thrombosis among patients with atrial fibrillation (AF) and concomitant coronary artery disease (CAD), according to a new study. 

However, there is a difference between the two types of therapy in terms of their effect on major bleeding and stent thrombosis among patients taking DATT with direct oral anticoagulants (DOACs).

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To reach these conclusions, the researchers analyzed 9 studies that were identified via MEDLINE, Cochrane, or ClinicalTrials.gov from inception to May 1, 2019, and that had compared the safety and efficacy between DATT and TATT among patients with AF and CAD.

Together, the studies comprised 6104 patients who had received DATT and 7333 patients who had received TATT. 

While there was no statistically significant difference between the two groups regarding the outcomes of mortality, nonfatal MI, stent thrombosis, and stroke, the researchers did find a lower rate of major bleeding among patients taking DATT.

And although there was no significant difference between DATT and TATT regarding stent thrombosis, a subgroup analysis of trials with DOAC users showed a borderline higher rate of stent thrombosis among DATT users; these patients had a 66% increase in relative risk of stent thrombosis. 

“Existing study data demonstrate the safety of DATT in terms of reduction in bleeding outcomes with no significant difference in efficacy outcomes, making DATT the preferred strategy in patients with AF and concomitant CAD,” the researchers concluded. “However, the potential increase in stent thrombosis is a serious concern when choosing DATT for patients at a higher risk of ischemic events.”

—Colleen Murphy

Reference:

Ravi V, Pulipati P, Vij A, Kodumuri V. Meta-analysis comparing double versus triple antithrombotic therapy in patients with atrial fibrillation and coronary artery disease. Am J Cardiol. 2020;125(1):19-28. https://doi.org/10.1016/j.amjcard.2019.09.045.