Dual Versus Triple Therapy for Atrial Fibrillation After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

Ann Intern Med. 2020 Apr 7;172(7):474-483. doi: 10.7326/M19-3763. Epub 2020 Mar 17.


Background: The safety and effectiveness of dual therapy (direct oral anticoagulant [DOAC] plus P2Y12 inhibitor) versus triple therapy (vitamin K antagonist plus aspirin and P2Y12 inhibitor) in patients with nonvalvular atrial fibrillation (AF) after percutaneous coronary intervention (PCI) is unclear.

Purpose: To examine the effects of dual versus triple therapy on bleeding and ischemic outcomes in adults with AF after PCI.

Data sources: Searches of PubMed, EMBASE, and the Cochrane Library (inception to 31 December 2019) and ClinicalTrials.gov (7 January 2020) without language restrictions; journal Web sites; and reference lists.

Study selection: Randomized controlled trials that compared the effects of dual versus triple therapy on bleeding, mortality, and ischemic events in adults with AF after PCI.

Data extraction: Two independent investigators abstracted data, assessed the quality of evidence, and rated the certainty of evidence.

Data synthesis: Four trials encompassing 7953 patients were selected. At the median follow-up of 1 year, high-certainty evidence showed that dual therapy was associated with reduced risk for major bleeding compared with triple therapy (risk difference [RD], -0.013 [95% CI, -0.025 to -0.002]). Low-certainty evidence showed inconclusive effects of dual versus triple therapy on risks for all-cause mortality (RD, 0.004 [CI, -0.010 to 0.017]), cardiovascular mortality (RD, 0.001 [CI, -0.011 to 0.013]), myocardial infarction (RD, 0.003 [CI, -0.010 to 0.017]), stent thrombosis (RD, 0.003 [CI, -0.005 to 0.010]), and stroke (RD, -0.003 [CI, -0.010 to 0.005]). The upper bounds of the CIs for these effects were compatible with possible increased risks with dual therapy.

Limitation: Heterogeneity of study designs, dosages of DOACs, and types of P2Y12 inhibitors.

Conclusion: In adults with AF after PCI, dual therapy reduces risk for bleeding compared with triple therapy, whereas its effects on risks for death and ischemic end points are still unclear.

Primary funding source: None.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Acute Coronary Syndrome / surgery*
  • Aspirin / therapeutic use
  • Atrial Fibrillation / drug therapy*
  • Drug Therapy, Combination
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Percutaneous Coronary Intervention*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Postoperative Complications / drug therapy
  • Randomized Controlled Trials as Topic
  • Thrombolytic Therapy / methods*


  • Fibrinolytic Agents
  • Platelet Aggregation Inhibitors
  • Aspirin