For patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention
(PCI), antithrombotic therapy including oral anticoagulants and antiplatelets are
indicated. The optimal combination is not known. We investigated the efficacy and
safety of different antithrombotic strategies in patients with AF undergoing PCI.
PUBMED and EMBASE were searched through September 2019 for randomized trials investigating
the efficacy and safety of different antithrombotic strategies in patients with AF
who underwent PCI and/or acute coronary syndrome. Nine antithrombotic strategies were
compared including combinations of vitamin K antagonist (VKA) with dual antiplatelet
therapy (DAPT) or P2Y12 inhibitor, combinations of direct oral anticoagulants (DOAC)
(apixaban, dabigatran, rivaroxaban, and edoxaban) with DAPT or P2Y12 inhibitor (clopidogrel,
prasugrel, and ticagrelor). The primary safety outcome was trial defined primary bleeding
outcome. The primary efficacy outcome was trial defined major adverse cardiovascular
events. Our search identified 5 eligible trials that enrolled a total of 11,532 patients
and compared 9 treatment strategies. VKA + DAPT significantly increased bleeding when
compared with most combinations (for example, vs VKA + P2Y12 inhibitor: odds ratio
2.11; 95% confidence interval [1.76 to 2.52], p <0.001). Of all the combinations,
apixaban + P2Y12 inhibitor showed the lowest bleeding risk (for example, vs VKA + P2Y12
inhibitor: odds ratio 0.63; 95% confidence interval [0.51 to 0.78], p <0.001) and
was ranked the best treatment. There were no significant differences in ischemic outcome
of major adverse cardiovascular events between various antithrombotic regimens. In
conclusion, in patients with AF undergoing PCI, apixaban + P2Y12 inhibitors were associated
with lowest bleeding compared with other regimens including other DOACs + P2Y12 inhibitors
with no increase in ischemic outcomes.