Background: Choosing antithrombotic regime in patients with acute coronary syndrome (ACS) with concomitant indication for anticoagulation is a challenge commonly encountered by clinicians.
Objective: We aimed to evaluate safety and efficacy of triple (anticoagulant + dual antiplatelet-TT) versus dual (anticoagulant + single antiplatelet-DT) antithrombotic therapy in patients with ACS.
Methods: We included all randomized trials comparing outcomes of single versus dual antiplatelet therapy in ACS patients on anticoagulants. Primary outcome was major adverse cardiac events (MACE). Other outcomes studied were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST) and major bleeding. Mantel-Haenszel risk ratio (RR) random effects model was used to summarize data.
Results: Six studies with a total of 11,437 patients met our inclusion criteria. With a follow-up duration of 9-14 months, there was no difference between DT and TT in terms of MACE (RR 0.96, 95%CI 0.79-1.17), all-cause mortality (RR 1.00, 95%CI 0.77-1.29), cardiovascular mortality (RR1.03, 95%CI 0.79-1.34), MI (RR 1.14, 95% CI 0.90-1.45), stroke (RR 0.83, 95% CI 0.56-1.23) and ST (RR 1.32,95%CI 0.87-2.01). Compared with TT, DT was associated with significant reduction in major bleeding 4.1% vs 6.5% (RR 0.61, 95%CI 0.45-0.81, NNT=42), clinically significant bleeding (RR 0.62, 95%CI 0.48-0.80) and intracranial hemorrhage (RR 0.43, 95%CI 0.24-0.77).
Conclusion: In patients on anticoagulant therapy, single antiplatelet strategy confers benefit of less major bleeding with no difference in MACE, all-cause mortality, cardiovascular mortality, MI, stroke and ST.