Post-ACS patients do not benefit from addition of a NOAC to DAPT
Meta-Analysis of the Safety and Efficacy of the Oral Anticoagulant Agents (Apixaban, Rivaroxaban, Dabigatran) in Patients With Acute Coronary SyndromeLiterature - Khan SU, Arshad A, Riaz IB, et al. - Am J Cardiol 2018;121:301–307
- In 31,574 patients, addition of a NOAC to SAP did not increase the risk of clinically significant bleeding (HR: 0.82; 95%CI: 0.56-1.20; P=0.31), and had no beneficial efficacy effect on MACE (HR: 0.82; 95%CI: 0.66-1.04; P=0.10).
- A modest reduction in MACE was achieved when a NOAC was combined with DAPT (HR: 0.86; 95%CI: 0.78- 0.93; P<0.001), which was accompanied by a more than doubled risk of bleeding (HR: 2.24; 95%CI: 1.75-2.87; P<0.001).
- In subgroup analyses that assessed the effects of individual NOACs, dabigatran plus SAP was a safer approach compared with control (HR: 0.51; 95%CI: 0.42-0.61; P<0.001), and only rivaroxaban plus DAPT showed a significant 17% reduction in MACE. All the individual NOACs increased bleeding risk significantly when added to DAPT without achieving a meaningful MACE benefit.
In patients with recent ACS, addition of NOAC to single antiplatelet therapy did not result in excessive bleeding events or reduction in MACE. Addition of NOAC to dual antiplatelet therapy did result in a modest MACE reduction but led to an increased bleeding risk. Among NOACs, only rivaroxaban plus DAPT reduced the risk of MACE, and dabigatran plus SAP was the safest approach.