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Background: The optimal long-term antithrombotic strategy in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) remains uncertain. Individual randomized controlled trials (RCTs) had variations in their reported results and were not powered for effectiveness outcomes.
Objectives: This study aimed to pool the results of RCTs comparing the effectiveness and safety of oral anticoagulation (OAC) monotherapy vs OAC plus single antiplatelet therapy (SAPT) in patients with AF and stable CAD.
Methods: We systematically searched PubMed, Embase, and ClinicalTrials.gov until September 09, 2024. The primary effectiveness outcome was a composite of myocardial infarction, ischemic stroke, systemic embolism, or death. The primary safety outcome was major bleeding. We obtained unpublished results from principal investigators of the included RCTs, as needed, to calculate pooled HRs and 95% CIs and to perform prespecified subgroup analyses.
Results: Among 690 screened records, 4 RCTs with 4,092 randomized patients were included (2 using edoxaban, 1 using rivaroxaban, and 1 using any oral anticoagulant; mean age 73.9 years, 20.1% women). The median follow-up durations ranged from 12 to 30 months (overall estimated weighted mean follow-up of 21.9 months). There were no statistically significant differences between OAC monotherapy vs OAC plus SAPT in the primary effectiveness outcome (7.3% vs 8.2%; HR: 0.90; 95% CI: 0.72-1.12), myocardial infarction (1.0% vs 0.7%; HR: 1.51; 95% CI: 0.75-3.04), ischemic stroke (1.9% vs 2.1%; HR: 0.89; 95% CI: 0.57-1.37), all-cause death (4.2% vs 5.3%; HR: 0.94; 95% CI: 0.49-1.80), or cardiovascular death (2.4% vs 3.0%; HR: 0.79; 95% CI: 0.54-1.15). OAC monotherapy was associated with a lower risk of major bleeding than OAC plus SAPT (3.3% vs 5.7%; HR: 0.59; 95% CI: 0.44-0.79). Subgroup analyses did not show significant interactions for effectiveness but suggested that the magnitude of bleeding reduction may be greater among men (Pinteraction = 0.03) and among patients with diabetes mellitus (Pinteraction = 0.04).
Conclusions: In patients with AF and stable CAD, OAC monotherapy, compared with OAC plus SAPT, was not associated with a statistically significant increased risk of ischemic events but resulted in a significantly reduced risk of bleeding.
Guideline title 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke
Release date January 24, 2018
Prior version 2013
Developer American Heart Association (AHA)/American Stroke Association (ASA)
Funding source AHA/ASA
Target population Adult patients with acute arterial ischemic stroke
Major recommendations
Regional systems of stroke care should be developed that include health care facilities providing initial emergency care and those capable of endovascular stroke treatment, to which rapid transport can be arranged when appropriate (high-quality evidence; strong recommendation).
Intravenous alteplase is recommended for patients meeting detailed eligibility requirements within 3 hours of ischemic stroke onset (high-quality evidence; strong recommendation) and between 3 and 4.5 hours of ischemic stroke onset (moderate-quality evidence; strong recommendation).
Mechanical thrombectomy with a stent retriever is recommended for patients with a causative occlusion of the internal carotid artery or proximal middle cerebral artery with at least moderately severe presenting stroke deficits (National Institutes of Health Stroke Scale [NIHSS] score ≥6) and absence of evidence of widespread established infarction on brain imaging, when endovascular treatment can be initiated within 6 hours of symptom onset (high-quality evidence; strong recommendation).
Mechanical thrombectomy with a stent retriever is also recommended for certain acute ischemic stroke (AIS) patients presenting at later times (moderate- to high-quality evidence; strong recommendation).
