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Systematic Review ARTICLE Provisionally accepted The full-text will be published soon. Notify me

Front. Pharmacol. | doi: 10.3389/fphar.2018.01322

Antithrombotic regimens in patients with percutaneous coronary intervention whom an anticoagulant is indicated: a systematic review and network meta-analysis

 Wipharak Bunmark1,  Peerawat Jinatongthai2, Prin Vathesatogkit3, Ammarin Thakkinstian4, Christopher M. Reid5, 6, Wanwarang Wongcharoen7,  Nathorn Chaiyakunapruk8, 9, 10 and  Surakit Nathisuwan1*
  • 1Faculty of Pharmacy, Mahidol University, Thailand
  • 2Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Thailand
  • 3Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand
  • 4Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Thailand
  • 5Department of Epidemiology and Preventive Medicine, Monash University, Australia
  • 6School of Public Health, Curtin University, Australia
  • 7Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand
  • 8Center of Pharmaceutical Outcomes Research, Faculty of Pharmaceutical Sciences, Naresuan University, Thailand
  • 9School of Pharmacy, University of Wisconsin-Madison, United States
  • 10Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes, Monash University Malaysia, Malaysia

Background
Patients undergoing percutaneous coronary intervention (PCI) who require anticoagulant therapy are at increased risk of bleeding. The optimal regimen for these patients is uncertain. This study aimed to compare safety and efficacy of antithrombotic regimens used in patients undergoing PCI with concomitant anticoagulant therapy.

Methods
A systematic review and network meta-analysis was performed among studies comparing antithrombotic regimens for anticoagulated patients undergoing PCI. The primary outcome of interest was major bleeding. The secondary outcomes were coronary events. The reference intervention was classic triple therapy (aspirin plus clopidogrel plus vitamin K antagonist). Cluster rank incorporating risk (major bleeding) and benefit (all-cause death) was performed to identify the most appropriate regimen(s).

Results
There were 3 RCTs (6 interventions) and 29 non-RCTs (8 interventions) that met the inclusion criteria with 22,179 patients. Network meta-analysis of RCTs indicated that dual therapy (DT), either with vitamin K antagonist (VKA) or direct anticoagulant (DOAC) plus an antiplatelet, significantly reduced the risk of major bleeding compared to triple therapy (TT) [pooled RR of 0.51 (0.30-0.87) and 0.68 (0.49-0.94), respectively]. In addition, VKA-DT significantly reduced the risk of all-cause death compared to TT [pooled RR of 0.40 (0.17-0.93)]. Results from network meta-analysis of non-RCT paralleled that of RCTs. No significant differences of coronary events were found.

Conclusions
In conclusion, for anticoagulated patients undergoing PCI, dual therapy, either with warfarin or DOAC plus an antiplatelet, should be considered due to its optimal balance on efficacy and safety.

Keywords: Anticoagulant, Antithrombosis, Myocardial Infarction, Network meta-analysis, Percutaneous Coronary Intervention

Received: 04 Sep 2018; Accepted: 29 Oct 2018.

Edited by:

Brian Godman, Karolinska Institutet (KI), Sweden

Reviewed by:

Juhani Airaksinen, University of Turku, Finland
Tanja Mueller, University of Strathclyde, United Kingdom  

Copyright: © 2018 Bunmark, Jinatongthai, Vathesatogkit, Thakkinstian, Reid, Wongcharoen, Chaiyakunapruk and Nathisuwan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Surakit Nathisuwan, Faculty of Pharmacy, Mahidol University, Rajathevi, Thailand, surakit.nat@mahidol.ac.th