Photo Credit: freepik

The following is a summary of “Anticoagulation and Antiplatelet Therapy for Atrial Fibrillation and Stable Coronary Disease: Meta-analysis of Randomized Trials,” published in the January 2025 issue of Journal of the American College of Cardiology by Rashedi et al.

The optimal long-term antithrombotic strategy for patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) remains a subject of debate, as individual randomized controlled trials (RCTs) have yielded variable results and were often underpowered to assess effectiveness outcomes. This meta-analysis aimed to evaluate the comparative effectiveness and safety of oral anticoagulation (OAC) monotherapy versus OAC combined with single antiplatelet therapy (SAPT) in this patient population.

The primary effectiveness outcome was a composite of MI, ischemic stroke, systemic embolism, or death, while the primary safety outcome was major bleeding. Pooled HRs with 95% CIs were calculated using unpublished data from principal investigators where necessary, alongside prespecified subgroup analyses.

Of 690 screened records, four RCTs were included, encompassing 4,092 randomized patients (mean age: 73.9 years; 20.1% female) with median follow-up durations ranging from 12 to 30 months (weighted mean: 21.9 months). The trials included two studies using edoxaban, one using rivaroxaban, and one permitting any OAC. There was no statistically significant difference between OAC monotherapy and OAC plus SAPT in the primary effectiveness outcome (event rates: 7.3% vs. 8.2%; HR 0.90, 95% CI 0.72–1.12). Individual components of the composite outcome, including MI (1.0% vs. 0.7%; HR 1.51, 95% CI 0.75–3.04), ischemic stroke (1.9% vs. 2.1%; HR 0.89, 95% CI 0.57–1.37), all-cause death (4.2% vs. 5.3%; HR 0.94, 95% CI 0.49–1.80), and cardiovascular death (2.4% vs. 3.0%; HR 0.79, 95% CI 0.54–1.15), also showed no significant differences. However, OAC monotherapy was associated with a significantly lower risk of major bleeding compared to OAC plus SAPT (3.3% vs. 5.7%; HR 0.59, 95% CI 0.44–0.79). Subgroup analyses suggested greater reductions in bleeding risk among males (Pinteraction=0.03) and patients with diabetes mellitus (Pinteraction=0.04).

In conclusion, for patients with AF and stable CAD, OAC monotherapy provides comparable effectiveness to OAC plus SAPT in preventing ischemic events while significantly reducing the risk of major bleeding. These findings support the consideration of OAC monotherapy as a safer long-term strategy in this population.

Source: sciencedirect.com/science/article/abs/pii/S0735109725000713