Author + information
- Mahesh Anantha Narayanan1,
- Nagarjuna Gujjula2,
- Dixitha Anugula2,
- Yogesh NV. Reddy3,
- Janani Baskaran4 and
- Ganesh Raveendran4
In patients requiring long term anti coagulation, there is lack of consensus on optimal antiplatelet and anti thrombotic therapy in acute coronary syndrome (ACS). We performed a meta analysis to compare dual anti platelet therapy (DAPT) or dual therapy (DT) with triple therapy (TT) in ACS.
We searched 6 databases until June 2016 for clinical trials comparing DAPT (aspirin and clopidogrel) or DT (aspirin/clopidogrel with warfarin) versus TT (aspirin, clopidogrel and warfarin) in ACS using Random effects model.
Thirty-two studies including 2 RCTs with 37,939 patients were included. Mean follow up was 14 months and mean age 70.5 years. There was no difference in Major Adverse Cardiac Events (MACE)(Mantel Haenszel(MH)risk ratio(RR):1.10,95%CI:0.95-1.27,p=0.214) but Major Bleeding (MB) rates were lower in the DAPT/DT group compared to TT (MHRR:0.50,95%CI:0.37-0.69,p=0.001). Inclusion of only RCTs showed significantly lower rates of MACE (MHRR:0.60,95%CI:0.40-0.91,p=0.015) and MB in the DAPT /DT group (MHRR:0.44,95%CI:0.62-1.20,p=0.001). We analyzed 7 studies that used only TIMI bleeding score; MB was still lower in DAPT/DT group (MHRR:0.54,95%CI:0.32-0.91,p=0.020). Analysis of studies comparing only DT to TT showed no benefit to TT with no difference in MB and MACE.
Patients on DAPT/DT have lower rates of MB compared to TT. MACE were lower with DAPT/DT when analysis was restricted to only RCTs. Thus, TT cannot be recommended for patients with ACS requiring anticoagulation due to increase in MB and potentially an increase in MACE. Further large scale randomized trials are essential.
CORONARY: Acute Coronary Syndromes