Post Procedural Anticoagulation After Percutaneous Coronary Intervention in Patients With St-segment Elevation Myocardial Infarction : a Systematic Review and Meta-analysis

Post Procedural Anticoagulation After Percutaneous Coronary Intervention in Patients With St-segment Elevation Myocardial Infarction : a Systematic Review and Meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Post Procedural Anticoagulation After Percutaneous Coronary Intervention in Patients With St-segment Elevation Myocardial Infarction : a Systematic Review and Meta-analysis Ricardo Fonseca Oliveira Suruagy-Motta, Everton Victor Belmiro Da Silva, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6589467/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: This meta-analysis aims to evaluate the post-procedural anticoagulation in patients with ST-segment elevation after percutaneous coronary intervention Methods: A systematic review and meta-analysis search was conducted in the PubMed, Scoups, Embase, and Cochrane databases to identify relevant trials and cohort studies adhering and following the PRISMA established guidelines. The inclusion criteria covered studies that evaluate the use of PPA in STEMI patients after PCI, the exclusion criteria was studies that used the anticoagulation before and periprocedural and patients that underwent coronary artery bypass grafting. The main outcomes analyzed were all-cause mortality, cardiac death, reinfarction, stent thrombosis and stroke, comparing the group that used anticoagulation and the control group. Statistical analysis was performed using R software (version 4.2.3, R Foundation for Statistical Computing, Vienna, Austria) under the random-effects model to estimate pooled outcomes and assess heterogeneity. Results: Across the included studies, no statistically significant differences were observed between postprocedural anticoagulation (AC) and no anticoagulation (NAC) in any of the evaluated outcomes. For all-cause mortality (9 studies; 39,915 AC vs. 24,208 NAC), the pooled risk ratio (RR) was 0.76 [95% CI: 0.54–1.07; p = 0.1168; I² = 77.1%]. Cardiac death (6 studies; 32,523 AC vs. 17,190 NAC) showed an RR of 0.72 [95% CI: 0.49–1.05; p = 0.0906; I² = 77.7%]. Reinfarction (8 studies; 39,747 AC vs. 23,950 NAC) had an RR of 0.79 [95% CI: 0.48–1.31; p = 0.3657; I² = 82.3%]. For stent thrombosis (8 studies; 39,747 AC vs. 23,946 NAC), the RR was 1.17 [95% CI: 0.91–1.49; p = 0.2160; I² = 18.0%]. Stroke (8 studies; 39,839 AC vs. 24,116 NAC) showed an RR of 1.07 [95% CI: 0.75–1.51; p = 0.7170; I² = 29.1%], and bleeding (8 studies; 32,741 AC vs. 17,475 NAC) showed an RR of 0.96 [95% CI: 0.60–1.53; p = 0.8603; I² = 89.5%]. Finally, major adverse cardiovascular events (MACE) (6 studies; 32,523 AC vs. 17,186 NAC) had an RR of 0.71 [95% CI: 0.43–1.18; p = 0.1899; I² = 92.6%]. Conclusion: This meta-analysis shows that routine anticoagulation after primary PCI does not significantly reduce cardiovascular events, likely due to effective antiplatelet therapy and procedural advances. The findings align with current guidelines discouraging its routine use. A personalized approach remains essential to balance ischemic and bleeding risks. Anticoagulation PCI ST-segment elevation Myocardial Infarction Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 1. Introduction ST-segment elevation myocardial infarction (STEMI) is one of the most lethal cardiovascular emergencies, requiring immediate intervention. Primary percutaneous coronary intervention (PCI) is widely recognized as the most effective reperfusion strategy ( 1 ). After primary PCI, STEMI patients remain at risk for thrombotic events, such as stent thrombosis, especially in the first 30 days ( 2 ). Post-procedural anticoagulation is frequently administered to prevent these complications, either as a specific therapeutic indication or as routine prophylaxis ( 3 ). However, studies on the efficacy and safety of PPA have shown inconclusive results, associating it with high bleeding rates and unclear benefits in certain patient subgroups ( 3 ) ( 4 ). The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndrome suggest discontinuation of anticoagulants after invasive procedures. However, this recommendation carries only a level C evidence classification and lacks specific guidance regarding post-procedural anticoagulation following primary percutaneous coronary intervention (PCI)., The latest guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) states that the choice of post-PCI anticoagulation regimen should be individualized, considering factors such as bleeding risk and the need for concomitant antiplatelet therapy ( 2 ) ( 5 ). The main drugs used for anticoagulation after PCI include unfractionated heparin (UFH), bivalirudin, and low-molecular-weight heparins (LMWH), which are administered during and immediately after the procedure to prevent thrombosis. In some cases, patients with prolonged anticoagulation indications—such as those with atrial fibrillation—may be treated with direct oral anticoagulants (DOACs), including rivaroxaban, apixaban, or dabigatran, or vitamin K antagonists, such as warfarin, in combination with dual antiplatelet therapy. However, the prolonged use of these agents after PCI remains a topic of debate, requiring a careful risk-benefit assessment for each patient ( 6 ). This systematic review with meta-analysis aims to critically evaluate the data on anticoagulation after PCI in STEMI patients, assisting in the definition of safer and more effective therapeutic strategies. 2. Methods This systematic review and meta-analysis followed all of the guidelines and resolutions established and requested by Cochrane Handbook (7) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 statement (8). In addition, this project is registered in Prospero with the protocol number CRD420250654272. 2.1 Search strategy The search was conducted autonomously by the researchers in the subsequent databases: PubMed/MEDLINE; Cochrane; Embase and Scopus including all of the studies that report clinical outcomes of post percutaneous coronary intervention anticoagulation in the treatment of myocardial infarction. The search term used was: Boolean operators ("AND" and "OR") were applied to combine the following search terms “STEMI”; “ST-Elevation Myocardial Infarction”; “PCI”; “Percutaneous Coronary Intervention”; “postprocedural anticoagulation” this same strategy was used in all of the databases. The search strategy was developed using the PRESS ( Peer Review of Electronic Search Strategies ) validated method to ensure rigor and comprehensiveness. 2.2 Eligibility criteria 2.2.1 Inclusion criteria The main question for this systematic review was: "Is post-procedural anticoagulation both safe and effective for patients undergoing percutaneous coronary intervention for STEMI?” This question was substantiated and formulated using the PICOTT framework, with the following components: (P ) Patients with myocardial infarction that underwent percutaneous coronary interventions (I) Post procedural anticoagulation (C) Non post procedural anticoagulation (O) Death, Stroke, Reinfarction, Bleeding, Stroke (T) RCTs and Observational (T) No restriction 2.2.2 Exclusion criteria The exclusion criteria for this study were the following: 1) Studies that evaluate the benefit of pre procedural anticoagulation; 2) Studies that combined other therapies with the postprocedural anticoagulation; 3) Studies that evaluate the post-procedural anticoagulation in cardiac surgery procedures. In addition, case reports; reviews; conference abstracts and non-original research were not included in this meta-analysis. 2.3 Studies selection The first screening targeted mainly the title and abstract, without restrictions on the publication date, language or editorial. The articles were imported into the Rayyan platform (https://www.rayyan.ai/) (9). The following steps were title and abstract review. At this stage, all articles that did not directly pertain to the topic of interest were excluded, and duplicate titles were eliminated. This step was carried out independently by two reviewers (R.M and L.O), any uncertainties were resolved with the assistance of a third researcher (L.V) . 2.4 Endpoints and Definitions This meta-analysis targeted many endpoints, all of them were related to the impact of anticoagulation in cardiovascular events. In addition, the analyzed outcomes were all-cause death and cardiac death in both groups in the follow-up, events of reinfarction, stroke, stent thrombosis, major adverse cardiac events (MACE) and bleeding. 2.5 Data extraction The following data were extracted from the selected articles according to the study criteria: authors, year of publication, study location, type of study (RCTs or studies observational retrospective/prospective), sample size and age, patient characteristics , follow-up time, main outcomes (Death, bleeding, major adverse cardiac events, reinfarction, stroke and stent thrombosis). Two reviewers (G.Mand L.O) independently extracted and managed the data, which were recorded in an EXCEL® spreadsheet. Any doubts were resolved with the assistance of a third researcher (R.M). 2.6 Quality assessment The Risk Of Bias In Non-randomised Studies of Interventions tool (ROBINS-I) was applied to non-randomized studies, focusing on bias related to study design, confounding factors, participant selection, and outcome assessment (10) and the Risk of Bias in Randomized trials (ROB 2) was applied to randomized controlled trials and other clinical trials (11). Two independent reviewers (L.O and G.M) conducted the risk of bias assessments, assigning scores based on the established criteria for each tool. Discrepancies between reviewers were resolved through discussion, and when necessary, a third reviewer (R.M) was consulted to achieve consensus. Automated tools were not used during the risk of bias assessment; all evaluations were performed manually by experienced reviewers. 2.7 Statistical Analysis This meta-analysis was conducted in accordance with established methodological standards and guidelines. Statistical analyses were performed using R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria) and the meta package (12). P-values < 0.05 were considered statistically significant. This meta-analysis was conducted following established methodological standards and guidelines. A random-effects model was employed to account for potential heterogeneity across studies. For each outcome, risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were calculated. Statistical significance was defined as P-values < 0.05. Heterogeneity was assessed using the I² statistic, with values greater than 50% indicating substantial heterogeneity. Sensitivity analysis was conducted using the leave-one-out method to evaluate the influence of individual studies on the overall results. Funnel plots were generated for all analyzed outcomes to assess potential publication bias. All statistical analyses were performed in R (version 2024.12.1+563 "Kousa Dogwood") using the meta package, within the RStudio environment (13). 3. Results 3.1 Study selection A total of 126 records were identified from PubMed (n = 60), Embase (n = 40), SCOPUS (n = 7) and Cochrane (n = 5). After removing 45 duplicates, 81 records remained for title and abstract screening. Among these, 14 articles were selected for full-text evaluation. Ultimately, 9 studies met our inclusion criteria and were included in the final analysis, involving a total of 64,857 patients included in the final analysis (ref). This search process is illustrated in Fig. 1 . 3.2 Baseline characteristics of the included studies and patients Table 1 summarizes the characteristics of the studies included in this systematic review and meta-analysis evaluating outcomes of post-procedural anticoagulation in STEMI patients that underwent PCI. A total of 9 studies were analyzed, including 7 observational studies and 2 randomized controlled trials, with a total of 39,915 patients in the intervention group and 24,208 in the control group. Sample sizes ranged from 38 to 26,272 participants included in this study. The mean ages of participants ranged between 57.8 and 65 years, and follow-up periods were all 30 days. 3.3 - Outcomes: All-cause death : Forest plot in Fig. 2 shows the risk ratio (RR) in the all-cause death outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across nine studies, with a total of 39915 patients in the AC group and 24,208 in the NAC group. The pooled RR is 0.76 (95% CI: [0.54; 1.07]), with no significant difference (p = 0.1168). Heterogeneity is high, with I² = 77.1% and Chi² = 30.56 (p < 0.0001), indicating variability across the studies. Cardiac death: Forest plot in Fig. 3 shows the risk ratio (RR) in the Cardiac death outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across six studies, with a total of 32,523 patients in the AC group and 17,190 in the NAC group. The pooled RR is 0.72 (95% CI: [0.49; 1.05]), with no significant difference (p = 0.0906). Heterogeneity is high, with I² = 77.7% and Chi² = 22.39 (p = 0.0004), indicating variability across the studies. Reinfarction : Forest plot in Fig. 4 shows the risk ratio (RR) in the reinfarction outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across eight studies, with a total of 39,747 patients in the AC group and 23,950 in the NAC group. The pooled RR is 0.79 (95% CI: [0.48; 1.31]), with no significant difference (p = 0.3657). Heterogeneity is high, with I² = 82.3% and Chi² = 39.63 (p < 0.0001), indicating variability across the studies. Stent thrombosis : Forest plot in Fig. 5 shows the risk ratio (RR) in the stent thrombosis outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across eight studies, with a total of 39,747 patients in the AC group and 23,946 in the NAC group. The pooled RR is 1.17 (95% CI: [0.91; 1.49]), with no significant difference (p = 0.2160). Heterogeneity is low, with I² = 18.00% and Chi² = 8.54 (p = 0.2875), indicating consistent study results. Stroke : Forest plot in Fig. 6 shows the risk ratio (RR) in the stroke outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across eight studies, with a total of 39,839 patients in the AC group and 24,116 in the NAC group. The pooled RR is 1.07 (95% CI: [0.75; 1.51]), with no significant difference (p = 0.717). Heterogeneity is low, with I² = 29.1% and Chi² = 8.88 (p = 0.1957), indicating consistent results across studies. Bleeding : Forest plot in Fig. 7 shows the risk ratio (RR) in the bleeding outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across eight studies, with a total of 32,741 patients in the AC group and 17,475 in the NAC group. The pooled RR is 0.96 (95% CI: [0.60; 1.53]), with no significant difference (p = 0.8603). Heterogeneity is high, with I² = 89.5% and Chi² = 66.42 (p < 0.0001), indicating variability across the studies. Major Adverse Cardiovascular Events (MACE) : Fores plot in Fig. 8 shows the risk ratio (RR) in the Major Adverse Cardiovascular Events (MACE) outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across six studies, with a total of 32,523 patients in the AC group and 17,186 in the NAC group. The pooled RR is 0.71 (95% CI: [0.43; 1.18]), with no significant difference (p = 0.1899). Heterogeneity is high, with I² = 92.6% and Chi² = 67.52 (p < 0.0001), indicating variability across the studies. 3.4 Sensitivity analysis: Our sensitivity analysis for the death endpoint revealed that the overall result remained consistent after excluding each study, with Yan 2022 identified as the primary contributor to the observed heterogeneity. Excluding this study reduced the I² to 47% (Supplementary Fig. 2A) . Excluding Ducrocq 2019 led to significantly lower rates of cardiac death in the anticoagulation group (RR 0.64; 95% CI [0.43; 0.95]; I² = 62.9%) ( Supplementary Fig. 2B ). Finally, the leave-one-out analysis did not affect the overall effect for MACE or reinfarction endpoints. Additionally, omitting Gargiulo 2019 resulted in a significantly higher incidence of bleeding events in the anticoagulation group (RR 1.23; 95% CI [1.04; 1.47]; I² = 28.3%) ( Supplementary Fig. 2F ). 3.5 Quality assessment: Using the ROBINS-I tool, we assessed the risk of bias in five studies—Madhavan (2015), Chen (2019), Ducrocq (2016), Wang (2017), and Yan (2022)—across seven bias domains, with results illustrated in Supplementary Fig. 3A & 3B . For bias due to confounding (Domain 1), two studies—Madhavan (2015) and Yan (2022)—exhibited a serious risk, three showed moderate risk (Chen, 2019; Ducrocq, 2016; Wang, 2017), and none were rated as low risk. In bias in selection of participants (Domain 2), two studies demonstrated a moderate risk (Wang, 2017; Yan, 2022), while the other three (Madhavan, 2015; Chen, 2019; Ducrocq, 2016) were classified as low risk. In bias in classification of interventions (Domain 3), all five studies were rated as moderate risk. For bias due to deviations from intended interventions (Domain 4), three studies (Madhavan, 2015; Ducrocq, 2016; Yan, 2022) were assessed as moderate risk, and two—as exemplified by Chen (2019) and Wang (2017)—as low risk. Bias due to missing data (Domain 5) showed three studies with serious risk (Chen, 2019; Ducrocq, 2016; Wang, 2017), while the other two (Madhavan, 2015; Yan, 2022) exhibited moderate risk. In bias in measurement of outcomes (Domain 6), three studies had moderate risk (Yan, 2022; Wang, 2017; Chen, 2019), one had low risk (Madhavan, 2015), and one (Ducrocq, 2016) had serious risk. Bias in selection of the reported result (Domain 7) indicated two studies with low risk (Wang, 2017; Yan, 2022), one with moderate risk (Madhavan, 2015), and two with serious risk (Ducrocq, 2016; Chen, 2019). Overall, three studies were classified with moderate risk of bias, and two—Chen (2019) and Ducrocq (2016)—with serious risk. We utilized the RoB 2.0 tool to assess the risk of bias in four studies—Chang (2019), Gargiulio (2019), Song (2019), and Yan (2024)—across five bias domains, with results summarized in the Supplementary Fig. 4A & 4B . For bias arising from the randomization process (Domain 1), Yan (2024) showed a low risk, while the other three studies were reported as having some concerns. In bias due to deviations from intended interventions (Domain 2), Chang (2019) showed a high risk, while Gargiulio (2019) and Song (2019) demonstrated some concerns, and Yan (2024) was classified as low risk. Regarding bias due to missing outcome data (Domain 3) and bias in measurement of the outcome (Domain 4), all four studies were consistently rated as low risk. Chang (2019) and Song (2019) demonstrated some concerns regarding bias in the selection of the reported result (Domain 5), while Gargiulio (2019) and Yan (2024) demonstrated a low risk. Overall, these findings indicate that Chang (2019) carries a high risk of bias, while Gargiulio (2019) and Song (2019) showed some concerns, and Yan (2024) maintains a low risk. 4. Discussion This meta-analysis suggests that postprocedural anticoagulation does not provide a significant benefit in reducing adverse cardiovascular outcomes. Compared to the absence of anticoagulation, this strategy did not significantly lower the risks of stroke, stent thrombosis, reinfarction, or major adverse cardiovascular events (MACE), with heterogeneity ranging from low to high depending on the outcome assessed. Moreover, no significant impact was observed on all-cause or cardiac mortality. Bleeding rates also did not differ between groups, further underscoring the lack of a clear risk-benefit profile. Several plausible hypotheses may help explain the lack of significant benefit observed with postprocedural anticoagulation in this population. First, the adoption of dual antiplatelet therapy (DAPT) following PCI proposed by Kereiakes et al (2015) ( 23 ) — combining aspirin with a P2Y12 inhibitor — may already provide potent protection against thrombotic events, especially those mediated by platelet activation, such as early stent thrombosis. The addition of anticoagulation could represent a redundant strategy, targeting coagulation pathways that may play a secondary role in early post-PCI thrombosis. Second, the absolute incidence of thrombotic events post-primary PCI has declined significantly with the use of second- and third-generation drug-eluting stents and optimized antithrombotic protocols ( 24 – 26 ). In this context, even if anticoagulation offers some incremental benefit, its impact may be too small to achieve statistical significance in broad, unselected populations. The decision regarding the continuation of anticoagulation after PCI should balance the ischemic risk with the potential increase in bleeding events. A study conducted by Ducrocq et al. (2017) ( 16 ), suggested that prolonged administration of high-dose bivalirudin, for up to four hours post-procedure, could confer additional ischemic benefits in patients undergoing primary percutaneous coronary intervention. However, in a subsequent study, Gargiulo et al. (2019) ( 17 ) evaluated the infusion of bivalirudin and unfractionated heparin, with or without glycoprotein IIb/IIIa inhibitors, and found no significant reduction in adverse ischemic events post-procedure ( 2 ). Furthermore, the use of these strategies did not result in a substantial increase in bleeding complications, suggesting that post-procedural anticoagulation may not provide clinically relevant effects in this population. Despite the inclusion of a large and diverse population, our findings consistently demonstrated no statistically significant differences in stroke (RR: 1.07; 95% CI: 0.75-l1.51; p = 0.717), stent thrombosis (RR: 1.17; 95% CI: 0.91–1.49; p = 0.216), or reinfarction (RR: 0.79; 95% CI: 0.48–1.31; p = 0.365) between patients who received postprocedural anticoagulation and those who did not. Importantly, the low heterogeneity observed in stroke and stent thrombosis outcomes supports the consistency of these findings, while the high heterogeneity in reinfarction rates, later mitigated in sensitivity analysis by excluding the study by Gargiulo (2019) ( 17 ), suggests that certain study-specific characteristics may influence the apparent effect of anticoagulation. These results suggest that PPA does not offer additive protection in the prevention of thrombotic complications within the first 30 days post-PCI, the period in which ischemic risk is traditionally considered highest. Similarly, no significant reduction in either cardiac death (RR: 0.72; 95% CI: 0.49–1.05; p = 0.091) or all-cause mortality (RR: 0.76; 95% CI: 0.54–1.07; p = 0.117) was observed in the anticoagulation group, despite the large sample size analyzed. Sensitivity analyses highlighted that the study by Yan et al. (2022) ( 21 ) contributed disproportionately to heterogeneity in mortality outcomes, and its exclusion reduced I² from 77–47%. While these findings may hint at a possible benefit in select subgroups, particularly when outlier studies are removed, the overall lack of statistical significance limits definitive conclusions. Importantly, this also reinforces the need for more homogenous study designs and patient selection criteria in future research to clarify potential benefits in high-risk populations These findings align with the current uncertainty reflected in international guidelines. The 2020 European Society of Cardiology (ESC) guidelines for acute coronary syndromes recommend discontinuation of anticoagulation after PCI, but this recommendation is based on level C evidence and does not specifically address primary PCI in STEMI patients ( 5 ). Similarly, the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines acknowledge the need for individualized decision-making regarding post-PCI anticoagulation, especially in patients receiving dual antiplatelet therapy ( 2 ). The results of our meta-analysis provide empirical support for these cautious recommendations, reinforcing the notion that routine anticoagulation after primary PCI may not offer additional clinical benefit and should be reserved for selected cases with clear high risk for thrombotic events.. With regard to safety outcomes, bleeding events did not differ significantly between groups (RR: 0.96; 95% CI: 0.60–1.53; p = 0.860), although heterogeneity was high (I² = 89.5%). Notably, sensitivity analysis revealed that removing Gargiulo et al. (2019) resulted in a statistically significant increase in bleeding risk with anticoagulation (RR: 1.23; 95% CI: 1.04–1.47; I² = 28.3%), suggesting that certain regimens or patient profiles may be more vulnerable to hemorrhagic complications. This finding supports the concept of tailoring postprocedural antithrombotic strategies based on individual bleeding risk rather than applying a routine anticoagulation approach. Given the narrow therapeutic window in the acute post-PCI phase, future trials should aim to identify which subgroups, if any, derive net benefit from extended anticoagulation strategies and to optimize the balance between efficacy and safety. 5. Limitations The inclusion of a large patient population, totaling 64,857 individuals enhances the statistical power of the findings and minimizes the influence of random variability on the results. Furthermore, the inclusion of diverse classes of anticoagulants such as unfractionated heparin, bivalirudin, low-molecular-weight heparins, and direct oral anticoagulants broadens the scope of the review, allowing for a more comprehensive evaluation of available therapeutic strategies. However, the predominance of observational studies (7 out of 9) introduces a significant risk of bias, as these studies are inherently susceptible to uncontrolled confounders, such as the clinical indication for anticoagulation and the baseline severity of the disease. The follow-up period, limited to 30 days, while critical for assessing early thrombotic events, precludes an evaluation of medium- and long-term outcomes, including late stent thrombosis and hemorrhagic complications associated with prolonged anticoagulant use. The significant heterogeneity in the duration and type of post-procedural antithrombotic regimens employed across the included studies. While all studies evaluated patients undergoing PCI for STEMI, the choice and timing of anticoagulant or antiplatelet therapy varied considerably. For instance, Yan et al. used a combination of once-daily enoxaparin, intravenous unfractionated heparin (UFH), or bivalirudin; Wang et al. focused exclusively on bivalirudin; and Song et al. evaluated dual antiplatelet therapy with aspirin and a P2Y12 inhibitor. Ducrocq et al. compared bivalirudin with heparin, with or without the addition of glycoprotein IIb/IIIa inhibitors, while Chen (2019) used enoxaparin. This diversity in therapeutic protocols may have contributed to variability in clinical outcomes and limited the comparability across studies. Notably, Song and Wang represent particularly divergent approaches—one emphasizing antiplatelet therapy without anticoagulants, and the other relying solely on an anticoagulant—highlighting the extent of clinical heterogeneity among the trials. Additionally, the heterogeneity stemming from the inclusion of various therapeutic regimens, without a detailed subgroup analysis to differentiate their relative impacts on outcomes, warrants consideration. Finally, while Gargiulo (2019) and Song (2019) were classified as having some concerns across multiple domains particularly in the randomization process and the selection of reported results this raises uncertainty regarding the internal validity of their findings, emphasizing the need for cautious interpretation of the results 6. Conclusion This meta-analysis suggests that routine postprocedural anticoagulation does not significantly reduce the risk of adverse cardiovascular events in patients undergoing primary PCI. The lack of observed benefit is likely attributable to the already potent protection afforded by dual antiplatelet therapy and the advances in stent technology and procedural protocols, which have collectively diminished the incidence of thrombotic events. Although sensitivity analyses indicate that certain patient populations or specific regimens might exhibit differential effects, the overall consistency of these findings supports the current guideline recommendations that discourage routine use of extended anticoagulation in this setting. Importantly, the potential for increased bleeding risk in select scenarios underscores the need for a personalized approach, balancing ischemic protection with hemorrhagic risk. Future research should focus on identifying high-risk subgroups who may benefit from tailored anticoagulation strategies and on refining patient selection criteria to optimize clinical outcomes. Declarations Disclosures: All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. Funding: Not applicable – This meta-analysis received no external funding. Conflicts of Interests/Competing Interests: All authors report no relationships that could be construed as a conflict of interest. Availability of data and material - The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Code availability – Not applicable Author’s contribution – Conceptualization (R.S-M; E.S; T.F), Data curation and analysis (R.S-M; L.O, G.M, V.S), Methodology (R.S-M, C.F, V.D, B.B), Writing (R.S-M, L.O, V.S, F.M, B.B, W.G) Ethics approval – Not applicable Consent to participate – Not applicable Consent to publication – Not applicable References Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J . 7 de janeiro de 2018;39(2):119–77. Rao SV, O ’Donoghue Michelle L., Ruel M, Rab T, Tamis -Holland, Jaqueline E., Alexander JH, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. JACC [Internet]. 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Ducrocq G, Steg PG, Van't Hof A, et al Utility of post-procedural anticoagulation after primary PCI for STEMI: insights from a pooled analysis of the HORIZONS-AMI and EUROMAX trials. Eur Heart J Acute Cardiovasc Care. 2017 Oct;6(7):659-665. Gargiulo G, Carrara G, Frigoli E, et al. Post-Procedural Bivalirudin Infusion at Full or Low Regimen in Patients With Acute Coronary Syndrome. J Am Coll Cardiol. 2019 Feb 26;73(7):758-774. Madhavan MV, Généreux P, Kirtane AJ, et al. Is routine post-procedural anticoagulation warranted after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction? Insights from the HORIZONS-AMI trial. Eur Heart J Acute Cardiovasc Care . 2017 Oct;6(7):650-658. Song PS, Kim MJ, Jeon KH, et al. Efficacy of postprocedural anticoagulation after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A post-hoc analysis of the randomized INNOVATION trial. Medicine (Baltimore) . 2019 Apr;98(17):e15277. Wang H, Liang Z, Li Y, et al. Effect of postprocedural full-dose infusion of bivalirudin on acute stent thrombosis in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: Outcomes in a large real-world population. Cardiovasc Ther . 2017 Jun;35(3). Yan Y, Gong W, Ma C, et al. Postprocedure Anticoagulation in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. JACC Cardiovasc Interv. 14 de fevereiro de 2022;15(3):251–63. Yan Y, Guo J, Wang X, et al. Postprocedural Anticoagulation After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction: A Multicenter, Randomized, Double-Blind Trial. Circulation . 16 de abril de 2024;149(16):1258–67. Kereiakes DJ, Yeh RW, Massaro JM, et al. Antiplatelet therapy duration following bare metal or drug-eluting coronary stents: the dual antiplatelet therapy randomized clinical trial. JAMA. 2015 Mar 17;313(11):1113-21. Capodanno D, Alfonso F, Levine NG, et al. Acc/aha versus esc guidelines on dual antiplatelet therapy. J Am Coll Cardiol . (2018). 72:2915–31. 10.1016/j.jacc.2018.09.057 Généreux P, Giustino G, Witzenbichler B, Weisz G, Stuckey TD, Rinaldi MJ, et al. Incidence, predictors, and impact of post-discharge bleeding after percutaneous coronary intervention. J Am Coll Cardiol . (2015) 66:1036–45. 10.1016/j.jacc.2015.06.1323 Costa F, Klaveren DV, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT). score: a pooled analysis of individual patient datasets from clinical trials. Lancet . (2017) 389:1025–34. Table Table 1 is available in the Supplementary Files section Supplementary Files Table1anticoagulationPCI.xlsx SupplementaryFileACPOSTPCI2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6589467","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":454349063,"identity":"3d94106a-1394-4186-a051-21b28e8af993","order_by":0,"name":"Ricardo Fonseca Oliveira Suruagy-Motta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7ElEQVRIiWNgGAWjYDACZiT2gQ9Ago2dBC2MB2eAtDDjVItF92EedHuxAfN25ocPf7bdS+zvX2Nw2ObXNnk+ZgbGDx9zcGuROcxmbMzbVpw448Ybg8O5fbcN25gZmCVnbsOtRYKZh02asS0hseHGGaCWntuMQC1szLwEtEj+BGqZD9Ji2XPbnigtErxALRvO9xgcZvhxO5EILUC/8JxLMN54g63gYG/D7eQ2ZsZm/H7hP/zw4Y+yBNl55w9v/vDjz23b+e3NBz98xKMFSXOGAQNjG4jF2ECMeiDgP/6AgeEPkYpHwSgYBaNgRAEAI5RRlnaU3eQAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0001-6252-6708","institution":"CESMAC University Centre: Centro Universitario CESMAC","correspondingAuthor":true,"prefix":"","firstName":"Ricardo","middleName":"Fonseca Oliveira","lastName":"Suruagy-Motta","suffix":""},{"id":454349064,"identity":"abf6db74-e95b-49ec-b21f-bd7bfc06c74a","order_by":1,"name":"Everton Victor Belmiro Da Silva","email":"","orcid":"","institution":"Federal University of Pernambuco: Universidade Federal de 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10:37:45","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":7382,"visible":true,"origin":"","legend":"","description":"","filename":"Table1anticoagulationPCI.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-6589467/v1/108101c10b1592f05a9f3bf1.xlsx"},{"id":82795833,"identity":"52846cfd-4f8f-42bd-a0b1-ca170a820852","added_by":"auto","created_at":"2025-05-15 10:37:46","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":2615065,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFileACPOSTPCI2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6589467/v1/ec3cf1759c9fb9c0b3cd09a3.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003ePost Procedural Anticoagulation After Percutaneous Coronary Intervention in Patients With St-segment Elevation Myocardial Infarction : a Systematic Review and Meta-analysis\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eST-segment elevation myocardial infarction (STEMI) is one of the most lethal cardiovascular emergencies, requiring immediate intervention. Primary percutaneous coronary intervention (PCI) is widely recognized as the most effective reperfusion strategy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). After primary PCI, STEMI patients remain at risk for thrombotic events, such as stent thrombosis, especially in the first 30 days (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Post-procedural anticoagulation is frequently administered to prevent these complications, either as a specific therapeutic indication or as routine prophylaxis (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, studies on the efficacy and safety of PPA have shown inconclusive results, associating it with high bleeding rates and unclear benefits in certain patient subgroups (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndrome suggest discontinuation of anticoagulants after invasive procedures. However, this recommendation carries only a level C evidence classification and lacks specific guidance regarding post-procedural anticoagulation following primary percutaneous coronary intervention (PCI)., The latest guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) states that the choice of post-PCI anticoagulation regimen should be individualized, considering factors such as bleeding risk and the need for concomitant antiplatelet therapy (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe main drugs used for anticoagulation after PCI include unfractionated heparin (UFH), bivalirudin, and low-molecular-weight heparins (LMWH), which are administered during and immediately after the procedure to prevent thrombosis. In some cases, patients with prolonged anticoagulation indications\u0026mdash;such as those with atrial fibrillation\u0026mdash;may be treated with direct oral anticoagulants (DOACs), including rivaroxaban, apixaban, or dabigatran, or vitamin K antagonists, such as warfarin, in combination with dual antiplatelet therapy. However, the prolonged use of these agents after PCI remains a topic of debate, requiring a careful risk-benefit assessment for each patient (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis systematic review with meta-analysis aims to critically evaluate the data on anticoagulation after PCI in STEMI patients, assisting in the definition of safer and more effective therapeutic strategies.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis systematic review and meta-analysis followed all of the guidelines and resolutions established and requested by Cochrane Handbook (7) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 statement (8). In addition, this project is registered in Prospero with the protocol number CRD420250654272.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.1 Search strategy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe search was conducted autonomously by the researchers in the subsequent databases: PubMed/MEDLINE; Cochrane; Embase and Scopus including all of the studies that report clinical outcomes of post percutaneous coronary intervention anticoagulation in the treatment of myocardial infarction. The search term used was: Boolean operators (\u0026quot;AND\u0026quot; and \u0026quot;OR\u0026quot;) were applied to combine the following search terms \u0026ldquo;STEMI\u0026rdquo;; \u0026ldquo;ST-Elevation Myocardial Infarction\u0026rdquo;; \u0026ldquo;PCI\u0026rdquo;; \u0026ldquo;Percutaneous Coronary Intervention\u0026rdquo;; \u0026nbsp; \u0026ldquo;postprocedural anticoagulation\u0026rdquo; this same strategy was used in all of the databases. The search strategy was developed using the PRESS (\u003cem\u003ePeer Review of Electronic Search Strategies\u003c/em\u003e) validated method to ensure rigor and comprehensiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.2 Eligibility criteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.2.1 Inclusion criteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main question for this systematic review was: \u0026quot;Is post-procedural anticoagulation both safe and effective for patients undergoing percutaneous coronary intervention for STEMI?\u0026rdquo; This question was substantiated and formulated using the PICOTT framework, with the following components:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(P\u003c/strong\u003e) Patients with myocardial infarction that underwent percutaneous coronary interventions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(I)\u0026nbsp;\u003c/strong\u003ePost procedural anticoagulation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(C)\u0026nbsp;\u003c/strong\u003eNon post procedural anticoagulation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(O)\u0026nbsp;\u003c/strong\u003eDeath, Stroke, Reinfarction, Bleeding, Stroke\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(T)\u0026nbsp;\u003c/strong\u003eRCTs and Observational\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(T)\u0026nbsp;\u003c/strong\u003eNo restriction\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.2.2 Exclusion criteria\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe exclusion criteria for this study were the following: 1) Studies that evaluate the benefit of pre procedural anticoagulation; 2) Studies that combined other therapies with the postprocedural anticoagulation; 3) Studies that evaluate the post-procedural anticoagulation in cardiac surgery procedures. In addition, case reports; reviews; conference abstracts and non-original research were not included in this meta-analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3 Studies selection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first screening targeted mainly the title and abstract, without restrictions on the publication date, language or editorial. The articles were imported into the Rayyan platform (https://www.rayyan.ai/) (9). The following steps were title and abstract review. At this stage, all articles that did not directly pertain to the topic of interest were excluded, and duplicate titles were eliminated. This step was carried out independently by two reviewers (R.M and L.O), any uncertainties were resolved with the assistance of a third researcher (L.V) .\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.4 Endpoints and Definitions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis meta-analysis targeted many endpoints, all of them were related to the impact of anticoagulation in cardiovascular events. In addition, the analyzed outcomes were all-cause death and cardiac death in both groups in the follow-up, events of reinfarction, stroke, stent thrombosis, major adverse cardiac events (MACE) and bleeding.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.5 Data extraction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following data were extracted from the selected articles according to the study criteria: authors, year of publication, study location, type of study (RCTs or studies observational retrospective/prospective), sample size and age, patient characteristics , follow-up time, main outcomes (Death, bleeding, major adverse cardiac events, reinfarction, stroke and stent thrombosis). Two reviewers (G.Mand L.O) independently extracted and managed the data, which were recorded in an EXCEL\u0026reg; spreadsheet. Any doubts were resolved with the assistance of a third researcher (R.M).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.6 Quality assessment\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Risk Of Bias In Non-randomised Studies of Interventions tool (ROBINS-I) was applied to non-randomized studies, focusing on bias related to study design, confounding factors, participant selection, and outcome assessment (10) and the Risk of Bias in Randomized trials (ROB 2) was applied to randomized controlled trials and other clinical trials (11). Two independent reviewers (L.O and G.M) conducted the risk of bias assessments, assigning scores based on the established criteria for each tool. Discrepancies between reviewers were resolved through discussion, and when necessary, a third reviewer (R.M) was consulted to achieve consensus. Automated tools were not used during the risk of bias assessment; all evaluations were performed manually by experienced reviewers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.7 Statistical Analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis meta-analysis was conducted in accordance with established methodological standards and guidelines. Statistical analyses were performed using R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria) and the meta package (12). P-values \u0026lt; 0.05 were considered statistically significant. This meta-analysis was conducted following established methodological standards and guidelines. A random-effects model was employed to account for potential heterogeneity across studies. For each outcome, risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were calculated. Statistical significance was defined as P-values \u0026lt; 0.05. Heterogeneity was assessed using the I\u0026sup2; statistic, with values greater than 50% indicating substantial heterogeneity. Sensitivity analysis was conducted using the leave-one-out method to evaluate the influence of individual studies on the overall results. Funnel plots were generated for all analyzed outcomes to assess potential publication bias. All statistical analyses were performed in R (version 2024.12.1+563 \u0026quot;Kousa Dogwood\u0026quot;) using the meta package, within the RStudio environment (13).\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study selection\u003c/h2\u003e \u003cp\u003eA total of 126 records were identified from PubMed (n\u0026thinsp;=\u0026thinsp;60), Embase (n\u0026thinsp;=\u0026thinsp;40), SCOPUS (n\u0026thinsp;=\u0026thinsp;7) and Cochrane (n\u0026thinsp;=\u0026thinsp;5). After removing 45 duplicates, 81 records remained for title and abstract screening. Among these, 14 articles were selected for full-text evaluation. Ultimately, 9 studies met our inclusion criteria and were included in the final analysis, involving a total of 64,857 patients included in the final analysis (ref). This search process is illustrated in \u003cb\u003eFig.\u0026nbsp;1\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Baseline characteristics of the included studies and patients\u003c/h2\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e summarizes the characteristics of the studies included in this systematic review and meta-analysis evaluating outcomes of post-procedural anticoagulation in STEMI patients that underwent PCI. A total of 9 studies were analyzed, including 7 observational studies and 2 randomized controlled trials, with a total of 39,915 patients in the intervention group and 24,208 in the control group. Sample sizes ranged from 38 to 26,272 participants included in this study. The mean ages of participants ranged between 57.8 and 65 years, and follow-up periods were all 30 days.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3 - Outcomes:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eAll-cause death\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eForest plot in \u003cb\u003eFig.\u0026nbsp;2\u003c/b\u003e shows the risk ratio (RR) in the all-cause death outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across nine studies, with a total of 39915 patients in the AC group and 24,208 in the NAC group. The pooled RR is 0.76 (95% CI: [0.54; 1.07]), with no significant difference (p\u0026thinsp;=\u0026thinsp;0.1168). Heterogeneity is high, with I\u0026sup2; = 77.1% and Chi\u0026sup2; = 30.56 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), indicating variability across the studies.\u003c/p\u003e \u003cp\u003eCardiac death:\u003c/p\u003e \u003cp\u003eForest plot in \u003cb\u003eFig.\u0026nbsp;3\u003c/b\u003e shows the risk ratio (RR) in the Cardiac death outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across six studies, with a total of 32,523 patients in the AC group and 17,190 in the NAC group. The pooled RR is 0.72 (95% CI: [0.49; 1.05]), with no significant difference (p\u0026thinsp;=\u0026thinsp;0.0906). Heterogeneity is high, with I\u0026sup2; = 77.7% and Chi\u0026sup2; = 22.39 (p\u0026thinsp;=\u0026thinsp;0.0004), indicating variability across the studies.\u003c/p\u003e \u003cp\u003e \u003cb\u003eReinfarction\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eForest plot in \u003cb\u003eFig.\u0026nbsp;4\u003c/b\u003e shows the risk ratio (RR) in the reinfarction outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across eight studies, with a total of 39,747 patients in the AC group and 23,950 in the NAC group. The pooled RR is 0.79 (95% CI: [0.48; 1.31]), with no significant difference (p\u0026thinsp;=\u0026thinsp;0.3657). Heterogeneity is high, with I\u0026sup2; = 82.3% and Chi\u0026sup2; = 39.63 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), indicating variability across the studies.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStent thrombosis\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eForest plot in \u003cb\u003eFig.\u0026nbsp;5\u003c/b\u003e shows the risk ratio (RR) in the stent thrombosis outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across eight studies, with a total of 39,747 patients in the AC group and 23,946 in the NAC group. The pooled RR is 1.17 (95% CI: [0.91; 1.49]), with no significant difference (p\u0026thinsp;=\u0026thinsp;0.2160). Heterogeneity is low, with I\u0026sup2; = 18.00% and Chi\u0026sup2; = 8.54 (p\u0026thinsp;=\u0026thinsp;0.2875), indicating consistent study results.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStroke\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eForest plot in \u003cb\u003eFig.\u0026nbsp;6\u003c/b\u003e shows the risk ratio (RR) in the stroke outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across eight studies, with a total of 39,839 patients in the AC group and 24,116 in the NAC group. The pooled RR is 1.07 (95% CI: [0.75; 1.51]), with no significant difference (p\u0026thinsp;=\u0026thinsp;0.717). Heterogeneity is low, with I\u0026sup2; = 29.1% and Chi\u0026sup2; = 8.88 (p\u0026thinsp;=\u0026thinsp;0.1957), indicating consistent results across studies.\u003c/p\u003e \u003cp\u003e \u003cb\u003eBleeding\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eForest plot in \u003cb\u003eFig.\u0026nbsp;7\u003c/b\u003e shows the risk ratio (RR) in the bleeding outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across eight studies, with a total of 32,741 patients in the AC group and 17,475 in the NAC group. The pooled RR is 0.96 (95% CI: [0.60; 1.53]), with no significant difference (p\u0026thinsp;=\u0026thinsp;0.8603). Heterogeneity is high, with I\u0026sup2; = 89.5% and Chi\u0026sup2; = 66.42 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), indicating variability across the studies.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMajor Adverse Cardiovascular Events (MACE)\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eFores plot in \u003cb\u003eFig.\u0026nbsp;8\u003c/b\u003e shows the risk ratio (RR) in the Major Adverse Cardiovascular Events (MACE) outcome between postprocedural anticoagulation (AC) and non-anticoagulation (NAC) across six studies, with a total of 32,523 patients in the AC group and 17,186 in the NAC group. The pooled RR is 0.71 (95% CI: [0.43; 1.18]), with no significant difference (p\u0026thinsp;=\u0026thinsp;0.1899). Heterogeneity is high, with I\u0026sup2; = 92.6% and Chi\u0026sup2; = 67.52 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), indicating variability across the studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Sensitivity analysis:\u003c/h2\u003e \u003cp\u003eOur sensitivity analysis for the death endpoint revealed that the overall result remained consistent after excluding each study, with \u003cb\u003eYan 2022\u003c/b\u003e identified as the primary contributor to the observed heterogeneity. Excluding this study reduced the I\u0026sup2; to 47% \u003cb\u003e(Supplementary Fig.\u0026nbsp;2A)\u003c/b\u003e. Excluding \u003cb\u003eDucrocq 2019\u003c/b\u003e led to significantly lower rates of cardiac death in the anticoagulation group (RR 0.64; 95% CI [0.43; 0.95]; I\u0026sup2; = 62.9%) (\u003cb\u003eSupplementary Fig.\u0026nbsp;2B\u003c/b\u003e). Finally, the leave-one-out analysis did not affect the overall effect for MACE or reinfarction endpoints. Additionally, omitting \u003cb\u003eGargiulo 2019\u003c/b\u003e resulted in a significantly higher incidence of bleeding events in the anticoagulation group (RR 1.23; 95% CI [1.04; 1.47]; I\u0026sup2; = 28.3%) (\u003cb\u003eSupplementary Fig.\u0026nbsp;2F\u003c/b\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Quality assessment:\u003c/h2\u003e \u003cp\u003eUsing the ROBINS-I tool, we assessed the risk of bias in five studies\u0026mdash;Madhavan (2015), Chen (2019), Ducrocq (2016), Wang (2017), and Yan (2022)\u0026mdash;across seven bias domains, with results illustrated in \u003cb\u003eSupplementary Fig.\u0026nbsp;3A \u0026amp; 3B\u003c/b\u003e. For bias due to confounding (Domain 1), two studies\u0026mdash;Madhavan (2015) and Yan (2022)\u0026mdash;exhibited a serious risk, three showed moderate risk (Chen, 2019; Ducrocq, 2016; Wang, 2017), and none were rated as low risk. In bias in selection of participants (Domain 2), two studies demonstrated a moderate risk (Wang, 2017; Yan, 2022), while the other three (Madhavan, 2015; Chen, 2019; Ducrocq, 2016) were classified as low risk. In bias in classification of interventions (Domain 3), all five studies were rated as moderate risk. For bias due to deviations from intended interventions (Domain 4), three studies (Madhavan, 2015; Ducrocq, 2016; Yan, 2022) were assessed as moderate risk, and two\u0026mdash;as exemplified by Chen (2019) and Wang (2017)\u0026mdash;as low risk. Bias due to missing data (Domain 5) showed three studies with serious risk (Chen, 2019; Ducrocq, 2016; Wang, 2017), while the other two (Madhavan, 2015; Yan, 2022) exhibited moderate risk. In bias in measurement of outcomes (Domain 6), three studies had moderate risk (Yan, 2022; Wang, 2017; Chen, 2019), one had low risk (Madhavan, 2015), and one (Ducrocq, 2016) had serious risk. Bias in selection of the reported result (Domain 7) indicated two studies with low risk (Wang, 2017; Yan, 2022), one with moderate risk (Madhavan, 2015), and two with serious risk (Ducrocq, 2016; Chen, 2019). Overall, three studies were classified with moderate risk of bias, and two\u0026mdash;Chen (2019) and Ducrocq (2016)\u0026mdash;with serious risk.\u003c/p\u003e \u003cp\u003eWe utilized the RoB 2.0 tool to assess the risk of bias in four studies\u0026mdash;Chang (2019), Gargiulio (2019), Song (2019), and Yan (2024)\u0026mdash;across five bias domains, with results summarized in the \u003cb\u003eSupplementary Fig.\u0026nbsp;4A \u0026amp; 4B\u003c/b\u003e. For bias arising from the randomization process (Domain 1), Yan (2024) showed a low risk, while the other three studies were reported as having some concerns. In bias due to deviations from intended interventions (Domain 2), Chang (2019) showed a high risk, while Gargiulio (2019) and Song (2019) demonstrated some concerns, and Yan (2024) was classified as low risk. Regarding bias due to missing outcome data (Domain 3) and bias in measurement of the outcome (Domain 4), all four studies were consistently rated as low risk. Chang (2019) and Song (2019) demonstrated some concerns regarding bias in the selection of the reported result (Domain 5), while Gargiulio (2019) and Yan (2024) demonstrated a low risk. Overall, these findings indicate that Chang (2019) carries a high risk of bias, while Gargiulio (2019) and Song (2019) showed some concerns, and Yan (2024) maintains a low risk.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis meta-analysis suggests that postprocedural anticoagulation does not provide a significant benefit in reducing adverse cardiovascular outcomes. Compared to the absence of anticoagulation, this strategy did not significantly lower the risks of stroke, stent thrombosis, reinfarction, or major adverse cardiovascular events (MACE), with heterogeneity ranging from low to high depending on the outcome assessed. Moreover, no significant impact was observed on all-cause or cardiac mortality. Bleeding rates also did not differ between groups, further underscoring the lack of a clear risk-benefit profile.\u003c/p\u003e \u003cp\u003eSeveral plausible hypotheses may help explain the lack of significant benefit observed with postprocedural anticoagulation in this population. First, the adoption of dual antiplatelet therapy (DAPT) following PCI proposed by Kereiakes et al (2015) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) \u0026mdash; combining aspirin with a P2Y12 inhibitor \u0026mdash; may already provide potent protection against thrombotic events, especially those mediated by platelet activation, such as early stent thrombosis. The addition of anticoagulation could represent a redundant strategy, targeting coagulation pathways that may play a secondary role in early post-PCI thrombosis. Second, the absolute incidence of thrombotic events post-primary PCI has declined significantly with the use of second- and third-generation drug-eluting stents and optimized antithrombotic protocols (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In this context, even if anticoagulation offers some incremental benefit, its impact may be too small to achieve statistical significance in broad, unselected populations.\u003c/p\u003e \u003cp\u003eThe decision regarding the continuation of anticoagulation after PCI should balance the ischemic risk with the potential increase in bleeding events. A study conducted by Ducrocq et al. (2017) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), suggested that prolonged administration of high-dose bivalirudin, for up to four hours post-procedure, could confer additional ischemic benefits in patients undergoing primary percutaneous coronary intervention. However, in a subsequent study, Gargiulo et al. (2019) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) evaluated the infusion of bivalirudin and unfractionated heparin, with or without glycoprotein IIb/IIIa inhibitors, and found no significant reduction in adverse ischemic events post-procedure (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Furthermore, the use of these strategies did not result in a substantial increase in bleeding complications, suggesting that post-procedural anticoagulation may not provide clinically relevant effects in this population.\u003c/p\u003e \u003cp\u003eDespite the inclusion of a large and diverse population, our findings consistently demonstrated no statistically significant differences in stroke (RR: 1.07; 95% CI: 0.75-l1.51; p\u0026thinsp;=\u0026thinsp;0.717), stent thrombosis (RR: 1.17; 95% CI: 0.91\u0026ndash;1.49; p\u0026thinsp;=\u0026thinsp;0.216), or reinfarction (RR: 0.79; 95% CI: 0.48\u0026ndash;1.31; p\u0026thinsp;=\u0026thinsp;0.365) between patients who received postprocedural anticoagulation and those who did not. Importantly, the low heterogeneity observed in stroke and stent thrombosis outcomes supports the consistency of these findings, while the high heterogeneity in reinfarction rates, later mitigated in sensitivity analysis by excluding the study by Gargiulo (2019) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), suggests that certain study-specific characteristics may influence the apparent effect of anticoagulation. These results suggest that PPA does not offer additive protection in the prevention of thrombotic complications within the first 30 days post-PCI, the period in which ischemic risk is traditionally considered highest. Similarly, no significant reduction in either cardiac death (RR: 0.72; 95% CI: 0.49\u0026ndash;1.05; p\u0026thinsp;=\u0026thinsp;0.091) or all-cause mortality (RR: 0.76; 95% CI: 0.54\u0026ndash;1.07; p\u0026thinsp;=\u0026thinsp;0.117) was observed in the anticoagulation group, despite the large sample size analyzed.\u003c/p\u003e \u003cp\u003eSensitivity analyses highlighted that the study by Yan et al. (2022) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) contributed disproportionately to heterogeneity in mortality outcomes, and its exclusion reduced I\u0026sup2; from 77\u0026ndash;47%. While these findings may hint at a possible benefit in select subgroups, particularly when outlier studies are removed, the overall lack of statistical significance limits definitive conclusions. Importantly, this also reinforces the need for more homogenous study designs and patient selection criteria in future research to clarify potential benefits in high-risk populations\u003c/p\u003e \u003cp\u003e These findings align with the current uncertainty reflected in international guidelines. The 2020 European Society of Cardiology (ESC) guidelines for acute coronary syndromes recommend discontinuation of anticoagulation after PCI, but this recommendation is based on level C evidence and does not specifically address primary PCI in STEMI patients (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Similarly, the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines acknowledge the need for individualized decision-making regarding post-PCI anticoagulation, especially in patients receiving dual antiplatelet therapy (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The results of our meta-analysis provide empirical support for these cautious recommendations, reinforcing the notion that routine anticoagulation after primary PCI may not offer additional clinical benefit and should be reserved for selected cases with clear high risk for thrombotic events..\u003c/p\u003e \u003cp\u003eWith regard to safety outcomes, bleeding events did not differ significantly between groups (RR: 0.96; 95% CI: 0.60\u0026ndash;1.53; p\u0026thinsp;=\u0026thinsp;0.860), although heterogeneity was high (I\u0026sup2; = 89.5%). Notably, sensitivity analysis revealed that removing Gargiulo et al. (2019) resulted in a statistically significant increase in bleeding risk with anticoagulation (RR: 1.23; 95% CI: 1.04\u0026ndash;1.47; I\u0026sup2; = 28.3%), suggesting that certain regimens or patient profiles may be more vulnerable to hemorrhagic complications. This finding supports the concept of tailoring postprocedural antithrombotic strategies based on individual bleeding risk rather than applying a routine anticoagulation approach. Given the narrow therapeutic window in the acute post-PCI phase, future trials should aim to identify which subgroups, if any, derive net benefit from extended anticoagulation strategies and to optimize the balance between efficacy and safety.\u003c/p\u003e"},{"header":"5. Limitations","content":"\u003cp\u003eThe inclusion of a large patient population, totaling 64,857 individuals enhances the statistical power of the findings and minimizes the influence of random variability on the results. Furthermore, the inclusion of diverse classes of anticoagulants such as unfractionated heparin, bivalirudin, low-molecular-weight heparins, and direct oral anticoagulants broadens the scope of the review, allowing for a more comprehensive evaluation of available therapeutic strategies. However, the predominance of observational studies (7 out of 9) introduces a significant risk of bias, as these studies are inherently susceptible to uncontrolled confounders, such as the clinical indication for anticoagulation and the baseline severity of the disease. The follow-up period, limited to 30 days, while critical for assessing early thrombotic events, precludes an evaluation of medium- and long-term outcomes, including late stent thrombosis and hemorrhagic complications associated with prolonged anticoagulant use.\u003c/p\u003e \u003cp\u003eThe significant heterogeneity in the duration and type of post-procedural antithrombotic regimens employed across the included studies. While all studies evaluated patients undergoing PCI for STEMI, the choice and timing of anticoagulant or antiplatelet therapy varied considerably. For instance, Yan et al. used a combination of once-daily enoxaparin, intravenous unfractionated heparin (UFH), or bivalirudin; Wang et al. focused exclusively on bivalirudin; and Song et al. evaluated dual antiplatelet therapy with aspirin and a P2Y12 inhibitor. Ducrocq et al. compared bivalirudin with heparin, with or without the addition of glycoprotein IIb/IIIa inhibitors, while Chen (2019) used enoxaparin. This diversity in therapeutic protocols may have contributed to variability in clinical outcomes and limited the comparability across studies. Notably, Song and Wang represent particularly divergent approaches\u0026mdash;one emphasizing antiplatelet therapy without anticoagulants, and the other relying solely on an anticoagulant\u0026mdash;highlighting the extent of clinical heterogeneity among the trials.\u003c/p\u003e \u003cp\u003eAdditionally, the heterogeneity stemming from the inclusion of various therapeutic regimens, without a detailed subgroup analysis to differentiate their relative impacts on outcomes, warrants consideration. Finally, while Gargiulo (2019) and Song (2019) were classified as having some concerns across multiple domains particularly in the randomization process and the selection of reported results this raises uncertainty regarding the internal validity of their findings, emphasizing the need for cautious interpretation of the results\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThis meta-analysis suggests that routine postprocedural anticoagulation does not significantly reduce the risk of adverse cardiovascular events in patients undergoing primary PCI. The lack of observed benefit is likely attributable to the already potent protection afforded by dual antiplatelet therapy and the advances in stent technology and procedural protocols, which have collectively diminished the incidence of thrombotic events. Although sensitivity analyses indicate that certain patient populations or specific regimens might exhibit differential effects, the overall consistency of these findings supports the current guideline recommendations that discourage routine use of extended anticoagulation in this setting. Importantly, the potential for increased bleeding risk in select scenarios underscores the need for a personalized approach, balancing ischemic protection with hemorrhagic risk. Future research should focus on identifying high-risk subgroups who may benefit from tailored anticoagulation strategies and on refining patient selection criteria to optimize clinical outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosures:\u0026nbsp;\u003c/strong\u003eAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable – This meta-analysis received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interests/Competing Interests:\u0026nbsp;\u003c/strong\u003eAll authors report no relationships that could be construed as a conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material -\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability –\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contribution –\u0026nbsp;\u003c/strong\u003eConceptualization (R.S-M; E.S; T.F), Data curation and analysis (R.S-M; L.O, G.M, V.S), Methodology (R.S-M, C.F, V.D, B.B), Writing (R.S-M, L.O, V.S, F.M, B.B, W.G)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval –\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate –\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication –\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eIbanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). \u003cstrong\u003eEur Heart J\u003c/strong\u003e. 7 de janeiro de 2018;39(2):119\u0026ndash;77.\u003c/li\u003e\n \u003cli\u003eRao SV, O \u0026rsquo;Donoghue Michelle L., Ruel M, Rab T, Tamis -Holland, Jaqueline E., Alexander JH, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. \u003cstrong\u003eJACC [Internet].\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eChen PF, Yi JL, Pei JY, Tang L, Fang ZF, Zhou SH, et al. 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Eur Heart J. 2021;42(14):1289\u0026ndash;1367. doi:10.1093/eurheartj/ehaa575\u003c/li\u003e\n \u003cli\u003eCalderaro D, Bichuette LD, Maciel PC, Cardozo FAM, Ribeiro HB, Gualandro DM, et al. Atualiza\u0026ccedil;\u0026atilde;o da Diretriz de Avalia\u0026ccedil;\u0026atilde;o Cardiovascular Perioperat\u0026oacute;ria da Sociedade Brasileira de Cardiologia: Foco em Manejo dos Pacientes com Interven\u0026ccedil;\u0026atilde;o Coron\u0026aacute;ria Percut\u0026acirc;nea \u0026ndash; 2022. Arq Bras Cardiol. 15 de fevereiro de 2022;118(2):536\u0026ndash;47.\u003c/li\u003e\n \u003cli\u003eHiggins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). \u003cem\u003eCochrane Handbook for Systematic Reviews of Interventions\u003c/em\u003e version 6.5 (updated August 2024). \u003cstrong\u003eCochrane\u003c/strong\u003e, 2024.\u003c/li\u003e\n \u003cli\u003ePage MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. 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Post-Procedural Anticoagulation After Primary Percutaneous Coronary Intervention for Anterior Acute Myocardial Infarction With Severe Left Ventricular Dysfunction. \u003cstrong\u003eCirc J\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eOff\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;J Jpn Circ Soc\u003c/strong\u003e. 25 de setembro de 2020;84(10):1728\u0026ndash;33.\u003c/li\u003e\n \u003cli\u003eDucrocq G, Steg PG, Van\u0026apos;t Hof A, et al Utility of post-procedural anticoagulation after primary PCI for STEMI: insights from a pooled analysis of the HORIZONS-AMI and EUROMAX trials. \u003cstrong\u003eEur Heart J Acute Cardiovasc Care.\u003c/strong\u003e 2017 Oct;6(7):659-665.\u003c/li\u003e\n \u003cli\u003eGargiulo G, Carrara G, Frigoli E, et al. Post-Procedural Bivalirudin Infusion at Full or Low Regimen in Patients With Acute Coronary Syndrome. \u003cstrong\u003eJ Am Coll Cardiol.\u003c/strong\u003e 2019 Feb 26;73(7):758-774.\u003c/li\u003e\n \u003cli\u003eMadhavan MV, G\u0026eacute;n\u0026eacute;reux P, Kirtane AJ, et al. Is routine post-procedural anticoagulation warranted after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction? Insights from the HORIZONS-AMI trial. \u003cstrong\u003eEur Heart J Acute Cardiovasc Care\u003c/strong\u003e. 2017 Oct;6(7):650-658.\u003c/li\u003e\n \u003cli\u003eSong PS, Kim MJ, Jeon KH, et al. Efficacy of postprocedural anticoagulation after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A post-hoc analysis of the randomized INNOVATION trial. \u003cstrong\u003eMedicine (Baltimore)\u003c/strong\u003e. 2019 Apr;98(17):e15277.\u003c/li\u003e\n \u003cli\u003eWang H, Liang Z, Li Y, et al. Effect of postprocedural full-dose infusion of bivalirudin on acute stent thrombosis in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: Outcomes in a large real-world population. \u003cstrong\u003eCardiovasc Ther\u003c/strong\u003e. 2017 Jun;35(3).\u003c/li\u003e\n \u003cli\u003eYan Y, Gong W, Ma C, et al. Postprocedure Anticoagulation in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. \u003cstrong\u003eJACC Cardiovasc Interv.\u003c/strong\u003e 14 de fevereiro de 2022;15(3):251\u0026ndash;63.\u003c/li\u003e\n \u003cli\u003eYan Y, Guo J, Wang X, et al. Postprocedural Anticoagulation After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction: A Multicenter, Randomized, Double-Blind Trial. \u003cstrong\u003eCirculation\u003c/strong\u003e. 16 de abril de 2024;149(16):1258\u0026ndash;67.\u003c/li\u003e\n \u003cli\u003eKereiakes DJ, Yeh RW, Massaro JM, et al. Antiplatelet therapy duration following bare metal or drug-eluting coronary stents: the dual antiplatelet therapy randomized clinical trial.\u003cstrong\u003eJAMA.\u0026nbsp;\u003c/strong\u003e2015 Mar 17;313(11):1113-21.\u003c/li\u003e\n \u003cli\u003eCapodanno D, Alfonso F, Levine NG, et al. Acc/aha versus esc guidelines on dual antiplatelet therapy.\u003cstrong\u003e\u0026nbsp;J Am Coll Cardiol\u003c/strong\u003e. (2018). 72:2915\u0026ndash;31. 10.1016/j.jacc.2018.09.057\u003c/li\u003e\n \u003cli\u003eG\u0026eacute;n\u0026eacute;reux P, Giustino G, Witzenbichler B, Weisz G, Stuckey TD, Rinaldi MJ, et al. Incidence, predictors, and impact of post-discharge bleeding after percutaneous coronary intervention.\u003cstrong\u003e\u0026nbsp;J Am Coll Cardiol\u003c/strong\u003e. (2015) 66:1036\u0026ndash;45. 10.1016/j.jacc.2015.06.1323\u003c/li\u003e\n \u003cli\u003eCosta F, Klaveren DV, James S, et al. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT). score: a pooled analysis of individual patient datasets from clinical trials. \u003cstrong\u003eLancet\u003c/strong\u003e. (2017) 389:1025\u0026ndash;34.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anticoagulation, PCI, ST-segment elevation, Myocardial Infarction","lastPublishedDoi":"10.21203/rs.3.rs-6589467/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6589467/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis meta-analysis aims to evaluate the post-procedural anticoagulation in patients with ST-segment elevation after percutaneous coronary intervention\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA systematic review and meta-analysis search was conducted in the PubMed, Scoups, Embase, and Cochrane databases to identify relevant trials and cohort studies adhering and following the PRISMA established guidelines. The inclusion criteria covered studies that evaluate the use of PPA in STEMI patients after PCI, the exclusion criteria was studies that used the anticoagulation before and periprocedural and patients that underwent coronary artery bypass grafting. The main outcomes analyzed were all-cause mortality, cardiac death, reinfarction, stent thrombosis and stroke, comparing the group that used anticoagulation and the control group. Statistical analysis was performed using R software (version 4.2.3, R Foundation for Statistical Computing, Vienna, Austria) under the random-effects model to estimate pooled outcomes and assess heterogeneity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcross the included studies, no statistically significant differences were observed between postprocedural anticoagulation (AC) and no anticoagulation (NAC) in any of the evaluated outcomes. For all-cause mortality (9 studies; 39,915 AC vs. 24,208 NAC), the pooled risk ratio (RR) was 0.76 [95% CI: 0.54–1.07; p = 0.1168; I² = 77.1%]. Cardiac death (6 studies; 32,523 AC vs. 17,190 NAC) showed an RR of 0.72 [95% CI: 0.49–1.05; p = 0.0906; I² = 77.7%]. Reinfarction (8 studies; 39,747 AC vs. 23,950 NAC) had an RR of 0.79 [95% CI: 0.48–1.31; p = 0.3657; I² = 82.3%]. For stent thrombosis (8 studies; 39,747 AC vs. 23,946 NAC), the RR was 1.17 [95% CI: 0.91–1.49; p = 0.2160; I² = 18.0%]. Stroke (8 studies; 39,839 AC vs. 24,116 NAC) showed an RR of 1.07 [95% CI: 0.75–1.51; p = 0.7170; I² = 29.1%], and bleeding (8 studies; 32,741 AC vs. 17,475 NAC) showed an RR of 0.96 [95% CI: 0.60–1.53; p = 0.8603; I² = 89.5%]. Finally, major adverse cardiovascular events (MACE) (6 studies; 32,523 AC vs. 17,186 NAC) had an RR of 0.71 [95% CI: 0.43–1.18; p = 0.1899; I² = 92.6%].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis meta-analysis shows that routine anticoagulation after primary PCI does not significantly reduce cardiovascular events, likely due to effective antiplatelet therapy and procedural advances. The findings align with current guidelines discouraging its routine use. A personalized approach remains essential to balance ischemic and bleeding risks.\u003c/p\u003e","manuscriptTitle":"Post Procedural Anticoagulation After Percutaneous Coronary Intervention in Patients With St-segment Elevation Myocardial Infarction : a Systematic Review and Meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 10:29:41","doi":"10.21203/rs.3.rs-6589467/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"82c76bb6-1ea9-4b72-9016-404d560c7db1","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-28T05:20:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-15 10:29:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6589467","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6589467","identity":"rs-6589467","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}