Lee SR, Rhee TM, Kang DY, et al. Meta-Analysis of Oral Anticoagulant Monotherapy as an Antithrombotic Strategy in Patients With Stable Coronary Artery Disease and Nonvalvular Atrial Fibrillation. Am J Cardiol. 2019 Jun 25. pii: S0002-9149(19)30705-2. doi: 10.1016/j.amjcard.2019.05.072. (Systematic review)

Guidelines recommend oral anticoagulant (OAC) monotherapy without antiplatelet therapy (APT) in patients with nonvalvular atrial fibrillation (AF) with stable coronary artery disease (CAD) of >1 year after myocardial infarction or percutaneous coronary intervention. More evidences are required for the safety and efficacy of OAC monotherapy compared with OAC plus APT. PubMed, EMBASE, and Cochrane Database of Systematic Reviews were systematically searched up to February 2019. Nonrandomized studies and randomized clinical trials comparing OAC monotherapy with OAC plus single APT (SAPT) for patients with stable CAD and nonvalvular AF. The primary end point was major adverse cardiovascular events (composite of ischemic or thrombotic events) and secondary outcomes included major bleeding, stroke, all-cause death, and net adverse events (composite of ischemic, thrombotic, or bleeding events). From 6 trials, 8,855 patients were included. There was no significant difference in major adverse cardiovascular event in patients with AF treated using OAC plus SAPT compared with those treated with OAC monotherapy (hazard ratio [HR] 1.09; 95% confidence interval [CI] 0.92 to 1.29). OAC plus SAPT was associated with a significantly higher risk of major bleeding compared with OAC monotherapy (HR 1.61; 95% CI 1.38 to 1.87), as well as in terms of net adverse event (HR 1.21; 95% CI 1.02 to 1.43). There were no significant differences in rates of stroke and all-cause death. In conclusion, in this meta-analysis, OAC monotherapy and OAC plus SAPT treatment showed similar effectiveness, but OAC monotherapy was significantly associated with a lower risk of bleeding compared with OAC plus SAPT in patients with nonvalvular AF and stable CAD.

Discipline Area Score
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Internal Medicine 6 / 7
Cardiology 6 / 7
Hemostasis and Thrombosis 6 / 7
Comments from MORE raters

General Internal Medicine-Primary Care(US) rater

I looked at the title and thought that is a big bunch of people. I felt that this meta-analysis reinforces what previous studies have shown, so in that respect physicians should be aware of this and should not over-treat their patients.

Hemostasis and Thrombosis rater

This study has limited validity because of its observational nature and the strong potential for confounding.

Hemostasis and Thrombosis rater

Well executed meta-anlaysis confirming the lack of need for an antiplatelet agent in anticoagulated patients for secondary prevention of CHD > 1 year after last ACS. It's an important basis to reduce common overuse of combined AC and AP (dual antithrombotic) therapy.

Internal Medicine rater

In this meta-analysis, the authors combine 5 nonrandomized designs and 1 RCT and attempt to ascertain the effects of warfarin lumped together with all DOACs with or without antiplatelets, including either aspirin or clopidogrel. Any study that is not randomized and considers all anticoagulants and all antiplatelets similarly is not one that I can rely on to change my practice. That being said, I still do try to stop aspirin in patients on anticoagulation after more than a year. The hard evidence for this will come only with an RCT and not a with combination of "apples and oranges" that we see here.

Internal Medicine rater

Minor point...it's good to see that someone has finally replaced the misnomer 'net clinical benefit' with the more accurate term 'net adverse events.'
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