Non-vitamin K antagonist oral anticoagulants (NOACs) may be associated with lower risks for adverse events requiring hospitalization and reduced rates of major bleeding compared with vitamin K antagonists in patients receiving percutaneous coronary intervention (PCI) for non-valvular atrial fibrillation who have an indication for anticoagulation, according to study results published in Cochrane Database Systematic Review.
In this systematic review and network meta-analysis, the data of randomized controlled trials indexed in CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index – Science, and 2 clinical trial registers, in which the outcomes of patients with an indication for anticoagulation who had undergone PCI and treated with NOACs vs vitamin K antagonists were examined.
The final network meta-analysis included 5 randomized controlled trials with a pooled cohort of 8373 participants. NOACs examined were apixaban (2 trials), rivaroxaban (2 trials), and dabigatran (1 trial), all of which were compared with a vitamin K antagonist.
NOACs and vitamin K antagonists were found to be associated with comparable rates of cardiovascular-related (for apixaban and rivaroxaban) and all-cause death, stroke, myocardial infarction, and stent thrombosis, based on very low- to moderate-level evidence. The risk for recurrent hospitalization was found to be lower in patients treated with apixaban (relative risk [RR], 0.85; 95% CI, 0.77-0.95), and high- and low-dose rivaroxaban (RR, 0.86; 95% CI, 0.74-1.00 and RR, 0.80; 95% CI, 0.68-0.92, respectively), compared with vitamin K antagonists.
Death from any cause was comparable in patients treated with apixaban or high-dose rivaroxaban (risk ratio [RR], 0.95; 95% CI, 0.36-2.48), and between patients treated with apixaban vs low-dose rivaroxaban (RR, 0.91; 95% CI, 0.35-2.35). The rate of MI was comparable in patients treated with: apixaban vs vitamin K antagonists (RR, 0.89; 95% CI, 0.65-1.20); high vs low doses of rivaroxaban (RR, 1.13; 95% CI, 0.59-2.16); high-dose rivaroxaban vs vitamin K antagonists (RR, 0.94; 95% CI, 0.53-1.65); and low-dose rivaroxaban vs vitamin K antagonists (RR, 0.80; 95% CI, 0.43-1.50).
Study limitations include the analysis of studies with a wide range of follow-up durations (6 months to 2.2 years) and the inclusion of 2 small post hoc subgroup analyses rather than the randomized trials.
“There may be little or no difference between NOACs and warfarin regarding efficacy outcomes, suggesting that NOACs may not cause harm due to reduced antithrombotic potency,” study investigator Dr Al Said told Cardiology Advisor. “Our network meta-analysis did not show superiority of one NOAC over another for any of the outcomes.”
“[U]sing NOACs in combination with antiplatelet therapy might be safer than triple therapy regimen of vitamin K antagonists plus dual antiplatelet therapy post-PCI,” concluded the study authors. “We found no clear evidence to inform guidelines about which NOAC agent should be used in preference to another for the management of individuals with indication for anticoagulation after PCI.”
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Al Said S, Alabed S, Kaier K, et al. Non-vitamin K antagonist oral anticoagulants (NOACs) post-percutaneous coronary intervention: a network meta-analysis. Cochrane Database Syst Rev. 2019;12:CD013252.