NOAC-Based Sual Therapy Versus Warfarin-Based Triple Therapy After Percutaneous Coronary Intervention or Acute Coronary Syndrome in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

Cardiovasc Revasc Med. 2020 Oct;21(10):1202-1208. doi: 10.1016/j.carrev.2020.03.012. Epub 2020 Mar 12.


Background: Several randomized clinical trials (RCTs) have compared the use of dual therapy (DT), or one of the non-vitamin K antagonist oral anticoagulants (NOAC) with a P2Y12 agent, versus triple therapy (TT), consisting of a vitamin-K antagonist (VKA) along with dual antiplatelet therapy, in patients with concomitant atrial fibrillation after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS). We performed a meta-analysis and systematic review of RCTs to evaluate the safety and efficacy of NOAC-based DT in such patients.

Methods: The major efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of mortality, myocardial infarction, stroke, stent thrombosis (ST), and urgent revascularization. The International Society on Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding (CRNM) was the major primary safety outcome.

Results: A total of 4 RCTs were included in the meta-analysis with 7942 total patients for analysis (DT: 4377 & TT: 3565). Compared to TT, DT resulted in similar risk of MACCE (OR: 1.12; 95% CI: 0.94-1.34; P = 0.20) and other efficacy endpoints with a trend in increased risk of ST in the DT group (1.55; 0.99-2.44; P = 0.06). DT resulted in lower risk of ISTH major or CRNM bleeding (0.56; 0.41-0.76; P < 0.01), and all other bleeding outcomes except for a trend of reduced risk of TIMI minor bleeding.

Conclusion: In conclusion, patients with atrial fibrillation who undergo PCI or develop ACS, NOAC-based dual therapy reduces bleeding outcomes without significantly increasing ischemic outcomes. Future trials should explore the possible differences in stent thrombosis.

Keywords: Atrial fibrillation; Dual therapy; PCI; Triple therapy.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Acute Coronary Syndrome* / drug therapy
  • Anticoagulants / therapeutic use
  • Atrial Fibrillation* / drug therapy
  • Drug Therapy, Combination
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Percutaneous Coronary Intervention*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Warfarin / therapeutic use


  • Anticoagulants
  • Fibrinolytic Agents
  • Platelet Aggregation Inhibitors
  • Warfarin