Physicians' Academy for Cardiovascular Education

Ischemic outcomes with antithrombotic regimes in AF patients with ACS or undergoing PCI

Revisiting the effects of omitting aspirin in combined antithrombotic therapies for atrial fibrillation and acute coronary syndromes or percutaneous coronary interventions: meta-analysis of pooled data from the PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS trials.

Literature - Potpara TS, Mujovic N, Proietti M, et al. - Europace 2019, doi: 10.1093/europace/euz259

Introduction and methods

Guidelines recommend triple antithrombotic therapy (TAT), consisting of an oral anticoagulant (OAC) and two antiplatelet agents (aspirin and a P2Y12 inhibitor) in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). TAT has been associated with increased risk of major bleeding [1], and an alternative therapy with reduced risk of bleeding is dual antithrombotic therapy (DAT), including an OAC and P2Y12 inhibitor.

RE-DUAL PCI [2] and PIONEER AF-PCI [3] demonstrated that a regimen of a NOAC (dabigatran and rivaroxaban, respectively) combined with a P2Y12 inhibitor (mostly clopidogrel) without aspirin resulted in reduced bleeding than TAT regimens with a VKA. In patients on a P2Y12 inhibitor, therapy regimens without aspirin and with apixaban showed less bleeding than regimens including aspirin, a VKA or both, as demonstrated in the AUGTUSTUS trial [5].

These three recent trials were not powered to detect differences of DAT or NOAC-based regimens in ischemic endpoints in comparison with TAT or VKA-based regiments and it is therefore questionable whether these regimens give optimal reduction of ischemic events in AF patients with ACS or PCI.

A meta-analysis of PIONEER AF-PCI, RE-DUAL PCI and AUGUSTUS including 9463 patients was conducted to compare DAT with TAT regimens and NOAC-based regimens with VKA-based therapies in AF patients with ACS or undergoing PCI.

Main results

DAT (no aspirin) vs TAT (with aspirin)



This meta-analysis of three trials including AF patients with ACS or undergoing PCI showed that 1) NOAC-based treatments were associated with less bleeding and similar risk for ischemic events and all-cause and CV mortality compared to VKA-based therapies and 2) DAT regimes compared to TAT were associated with reduced bleeding, similar risk of ischemic stroke, MI, pooled ischemic events, all-cause and CV mortality, but increased risk of stent thrombosis.

Future studies may provide answers on the timing of aspirin withdrawal and use of other P2Y12 inhibitors in combination with OAC.


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