New oral anticoagulants combined with antiplatelet therapy in the treatment of coronary heart disease: an updated meta-analysis

Abstract Objective New oral anticoagulants (NOACs) combined with antiplatelet therapy for acute coronary syndrome (ACS) may reduce ischemic events, but there is no consensus on bleeding risk. Moreover, the effect of NOACs on stable coronary artery disease (CAD) needs to be elucidated. We conducted a meta-analysis, to summarize the efficacy and safety of NOACs combined with antiplatelet therapy in the treatment of stable CAD and ACS.Methods We searched PubMed, Web of Science, and the Cochrane Library, then performed a systematic review of all 17 randomized controlled trials.Results For patients with stable CAD, rivaroxaban combined with antiplatelet therapy significantly reduced the rate of major adverse cardiovascular events (MACEs) (risk ratio; 95% confidence interval: 0.88; 0.81–0.95) and ischemic stroke (0.62; 0.50–0.77), with a relatively low risk of major bleeding (1.72; 1.42–2.07). For patients with ACS, the combination of NOACs could reduce the risk of MACEs (0.91; 0.85–0.97), myocardial infarction (MI) (0.90; 0.83–0.98) and ischemic stroke (0.75; 0.58–0.97), accompanied by increased non–fatal bleeding events and intracranial hemorrhage (3.42; 1.76–6.65). Results were similar when restricting the analysis to phase III studies except for the rate of stroke in patients with ACS.Conclusions Combination therapy can reduce the incidence of MI in ACS patients, but the risk of bleeding from intracranial hemorrhaging outweighs the benefit of MACEs driven by MI. That is due to combination therapy having no positive impact on mortality, thus the benefit-risk balance may be more favorable with patients with stable CAD.