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P2Y12 inhibitors with oral anticoagulation for percutaneous coronary intervention with atrial fibrillation: a systematic review and meta-analysis
  1. Florentino Lupercio1,
  2. Shaun Giancaterino1,
  3. Pedro Arturo Villablanca2,
  4. Frederick Han1,
  5. Kurt Hoffmayer1,
  6. Gordon Ho1,
  7. Farshad Raissi1,
  8. David Krummen1,
  9. Ulrika Birgersdotter-Green1,
  10. Gregory Feld1,
  11. Ryan Reeves1,
  12. Ehtisham Mahmud1,
  13. Jonathan C Hsu1
  1. 1 Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, La Jolla, California, USA
  2. 2 Division of Cardiology, Henry Ford Heart and Vascular Institute, Detroit, Michigan, USA
  1. Correspondence to Dr Jonathan C Hsu, Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, La Jolla, CA, USA; jonathan.hsu{at}


Objective This study aimed to compare the safety and efficacy of third-generation P2Y12 inhibitors versus clopidogrel in combination with oral anticoagulation (OAC) with or without aspirin in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).

Methods We performed a systematic review including both prospective and retrospective studies that compared dual and triple antithrombotic regimens for bleeding and major adverse cardiac events (MACE) in patients with AF undergoing PCI. We analysed rates of bleeding and MACE by P2Y12 inhibitor choice. Risk ratio (RR) 95% CIs were measured using the Mantel-Haenszel method. Where study heterogeneity was low (I2 <25%), we used the fixed effects model, otherwise the random effects model was used.

Results A total of 22 014 patients were analysed from the seven studies included. Among patients treated with both OAC and P2Y12 inhibitor with or without aspirin, 90% (n=9708) were treated with clopidogrel, 8% (n=830) with ticagrelor, and 2% (n=191) with prasugrel. When compared with clopidogrel, use of ticagrelor (RR 1.36; 95% CI 1.18 to 1.57) and prasugrel (RR 2.11; 95% CI 1.34 to 3.30) were associated with increased rates of bleeding. Compared with clopidogrel, there were no significant differences in rates of MACE with ticagrelor (RR 1.03; 95% CI 0.65 to 1.62) or prasugrel (RR 1.49; 95% CI 0.69 to 3.24).

Conclusion Based on this meta-analysis, the use of clopidogrel is associated with a lower rate of bleeding compared with ticagrelor or prasugrel in patients with AF on OAC undergoing PCI.

  • antiplatelet
  • atrial fibrillation
  • oral anticoagulation
  • P2Y12 inhibitor
  • percutaneous coronary intervention

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  • FL and SG are joint first authors.

  • FL and SG contributed equally.

  • Presented at An abstract of this study was presented as a poster at the 2019 Transcatheter Cardiovascular Therapeutics Symposium on 28 September 2019 in San Francisco, California. This abstract was published in a special issue of the Journal of the American College of Cardiology: Giancaterino S, Lupercio F, Villablanca P, et al. TCT-412 comparative safety and efficacy of second-generation P2Y12 inhibitors versus clopidogrel in combination with oral anticoagulation in atrial fibrillation patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Journal of the American College of Cardiology 2019;74:B408. FL has previously published a manuscript on a different topic that we were asked to cite and disclose: Lupercio F, Romero J, Peltzer B, et al. Efficacy and safety outcomes of direct oral anticoagulants and amiodarone in patients with atrial fibrillation. The American Journal of Medicine 2018;131:573.e1-573.e8.

  • Contributors All authors have read, approved and contributed meaningfully to the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JH has received honoraria from Medtronic, Abbott, Boston Scientific, Biotronik, Janssen Pharmaceutical, Bristol-Myers Squibb and Bio-sense-Webster and has received research grants from Biosense-Webster and Biotronik. GF, as CCEP Fellowship Training Program Director, receives fellowship training programme stipends from Medtronic, Biotronik, Biosense Webster, St. Jude/Abbott and Boston Scientific, Inc and has stock options or co-ownership in Acutus, Inc, toSense, Inc and Perminova, Inc.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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